Full text of "Narcotics research, rehabilitation, and treatment. Hearings, Ninety-second Congress, first session, pursuant to H. Res. 115 .."

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NARCOTICS RESEARCH, REHABILITATION,

AND TREATMENT

HEARINGS

BEFORE THE

SELECT COMMITTEE ON CRIME
HOUSE OF REPRESENTATIVES

NINETY-SECOND CONGEESS

FIRST SESSION '" '"

PUESUANT TO

H. RES. 115, A RESOLUTION CREATING A SELECT COMMITTEE
TO CONDUCT STUDIES AND INVESTIGATIONS OF
CRIME IN THE UNITED STATES

PART 1 OF 2 PARTS

APRIL 2Q, 27, 28, 1971 ; WASHINGTON, D.C.

Serial No. 92-1

Printed for the use of the Select Committee on Crime

U.S. GOVERNMENT PRINTING OFFICE

60-296 WASHINGTON : 1971

For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C, 20402 - Price .$1.50

NORTHEASTERN UNiVERSin SCHOQL of LAW IMM

SELECT COMMITTEE ON CRIME

CLAUDE PEPPER, Florida, Ghairman

JEROME R. WALDIE, California CHARLES E. WIGGINS, California

FRANK J. BRASCO, New York SAM STEIGER, Arizona

JAMES R. MANN, South Carolina LARRY WINN, Je., Kansas

MORGAN F. MURPHY, Illinois CHARLES W. SANDMAN, Jr., New Jersey-

CHARLES B. RANGEL, New York WILLIAM J. KEATING, Ohio

Paul L. Perito, Chief Counsel
Michael W. Blommer, Associate Chief Counsel

(n)

r»

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)

CONTENTS

April 26 1

April 27 77

April 28 209

June 2 341

June 3 _^____^ 391

June 4 .-. 481

June 23 553

Oral Statements by Government Witnesses

Health, Education, and Welfare, Department of:
Food and Drug Administration:

Edwards, Dr. Charles C, Commissioner : 393

Gardner, Dr. Elmer A., Consultant to the Director, Bureau of

Drugs ___ 393

Jennings, Dr. John, Associate Commissioner for Medical Affairs. 393
Health Services and Mental Health Administration:
National Institute of Mental Health:

Besteman, Dr. Karst, Acting Director, Division of Narcotics

and Drug Abuse 430. 439

Brown, Dr. Bertram, Director 430, 439

Martin, Dr. William, Chief, Addiction Research Center,

Lexington, Kj' 435,439

van Hoek, Dr. Robert, Associate Administrator for Operations. 430,439
Narcotics and Dangerous Drugs, Bureau of:

IngersoU, Hon. John E., Director 344, 439

Lewis, Dr. Edward, Chief Medical Officer 344, 439

Miller, Donald E., Chief Council 344, 439

Treasury, Department of, Hon. Eugene T. Rossides, Assistant Secretary,

Enforcement and Operations 61

Oral Statements by Public Witnesses

AREBA (Accelerated Reeducation of Emotions, Behavior, and Attitudes),
Dr. Daniel H. Casriel, director; accompanied by Rev. Raymond Massev
and Dr. Walter Rosen '_ 273

Brickley, Hon. James H., Lieutenant Governor, State of Michigan (on

behalf of Gov. William G. Milliken) 614

Brill, Dr. Henry, director, Pillgrim State (N.Y.) Hospital 51

Carter, Hon. James, Governor, State of Georgia 608

Casriel, Dr. Daniel H., director, AREBA (Accelerated Reeducation of

Emotions, Behavior, and Attitudes) 273

Chambers, Dr. Carl, director, division of research, New York State

Narcotic Addiction Control Commission 558

Davidson, Dr. Gerald E., a.ssociate director, Drug Dependency Clinic,

Boston City Hospital 322

Drug Dependency Clinic, Boston City Hospital, Dr. Gerald E. Davidson,

associate director ^^ ^ 322

DuPont, Dr. Robert L., Director, District of Columbia Narcotics Treat-
ment Administration 143

Eddy, Dr. Nathan B., Chairman, Committee on Problems of Dnig Depend-
ence, Division of ]\Iedical Sciences, National Academy of Sciences-
National Research Council 29

Gearing, Dr. R. Frances, associate professor, division of epidemiology,
Columbia University School of Public Health and Administrative
Medicine 105

Georgia, State of, Gov. James Carter ^ 608

(ra)

Page

Gollance, Dr. Harvey, associate director, Beth Israel Medical Center 239

Hesse, Rayburn F., special assistant to the chairman, Federal-State rela-
tions, New York State Narcotic Addiction Control Commission 5.58

Holden, William, department head, MITRE Corp 80

Holton, Hon. Linwood, Governor, Commonwealth of Virginia .594

Horan, Robert F., Jr., Commonwealth attorney, Fairfax County, Va 255

Illinois Drug Abuse Program, Dr. Jerome H. Jaffe, director 210

Institute of Applied Biology, Rev. Raymond ^Nlassey 273

Jaflfe, David, department staff, MITRE Corp 80

Jaflfe, Dr. Jerome H., director, Illinois Drug Abuse Program 210

Jones, Howard A., commissioner, New York State Narcotic Addiction

Control Commission 558

Kramer, Dr. John C, assistant professor, department of psychiatry and
human behavior, department of medical pharmacology, University of

California (Irvine) 642

Kurkmd, Dr. Albert A., director, Maryland State Psychiatric Research

Center 505

McCoy, William O., Maryland State Psychiatric Pi,esearch Center 506

Maryland State Psychiatric Research Center;

Kurland, Dr. Albert A., director 505

McCoj^, William ,506

Taylor, Robert 507

Masse}', Rev. Raymond, Institute of Applied Biology 273

Michigan, State of, Lt. Gov. James H. Brickley (on behalf of Gov. WiUiara

G. Milliken) 614

MITRE Corp 80

Holden, William, department head.
Jaffe, David, department staff.

Yondorf, Dr. Walter, associate director, national command and con-
trol division.
Narcotics Treatment Administration, District of Columbia, Dr. Robert L.

DuPont, Director 143

New York State Narcotic Addiction Control Commission:

Chambers, Dr. Carl, director, division of research 558

Hesse, Rayburn F., special assistant to the chairman, Federal-State

relations 558

Jones, Howard A., commissioner 558

Pennsylvania, Commonwealth of. Gov. Milton Shapp 602

Resnick, Dr. Richard B., associate professor, department of psychiatry,

New York Medical College 1 .539

Rosen, Dr. Walter, New York, N.Y 273

Seevers, Dr. Maurice H., chairman, department of pharmacology, University

of Michigan Medical School 9

Shapp, Hon. Milton, Governor, Commonwealth of Pennsylvania 602

Taylor, Robert, Maryland State Psychiatric Research Center 507

Villarreal, Dr. Julian E., associate professor of pharmacology, University

of Michigan Medical School 1 483

Virginia, Commonwealth of, Gov. Linwood Holton 594

Yondorf, Dr. Walter, associate director, national command and control

division, MITRE Corp 80

Exhibits Received for the Record

exhibit no. 1

American Medical Association, Dr. Richard S. Wilbur, deputy executive
vice president, letter dated July 9, 1971, to Paul L. Perito, chief counsel.
Select Committee on Crime 16

EXHIBIT NO. 2

Seevers, Dr. Maurice H., chairman, department of pharmacology, Univer-
sity of Michigan INIedical School, curriculum vitae 1 22

EXHIBIT NO. 3

Defense, U.S. Department of, Dr. Louis M. Rousselot, Assistant Secre-
tary, Health and Environment, letter dated June 28, 1971, to Chairman
Pepper, with attachments _ 24

EXHIBIT NO. 4 (a) AND (b)

Eddy, Dr. Nathan B., Chairman, Committee on Problems of Drug De-
pendence, Division of Medical Sciences, National Academj^ of Sciences-
National Research Council: P»Ke

(a) Prepared statement 40

(b) Curriculum vitae 42

EXHIBIT NO. 5 (a) AND (b)

Brill, Dr. Henry, director, Pilgrim State Hospital, New York, N.Y.:

(a) Prepared statement 58

(b) Curriculum vitae 59

EXHIBIT NO. 6

State, Department of, David M. Abshire, Assistant Secretary for Congres-
sional Relations, letter dated July 2, 1971, to Chairman Pepper, with
attachments 70

EXHIBIT NO. 7

Treasur}^ Department of, Eugene T. Rossides, Assistant Secretary for

Enforcement and Operations, curriculum vitae 75

EXHIBIT NO. 8 (a) AND (b)

Jaffe, David, department staff, MITRE Corp.:

(a) Supplemental statement 101

(b) Curriculum vitae 102

EXHIBIT NO. 9

Ulrich, William F., manager, applications research, scientific instruments
division, Beckman Instruments, Inc., prepared statement (dated
June 27, 1970) 103

EXHIBIT NO. 10 (a) AND (b)

Gearing, Dr. Francis R., associate professor, division of epidemiology^,
Columbia University School of Public Health and Administrative
Medicine :

(a) Paper entitled "Successes and Failures in Methadone Mainte-
nance Treatment of Heroin Addiction in New York City" 121

(b) Position paper entitled "Methadone — A Valid Treatment Tech-
nique" 138

EXHIBIT NO. 11 (a) THROUGH (e)

DuPont, Dr. Robert L., director. District of Columbia Narcotics Treat-
ment Administration :

(a) Article entitled "Profile of a Heroin Addict" 166

(b) Study entitled "Summary of 6-Month Followup Study" 178

(d) An administrative order setting forth guidelines for methadone
treatment 183

(e) Article entitled "A Study of Narcotics Addicted Offenders at the

D.C. Jail" '_ 195

EXHIBIT NO. 12

Jaffe, Dr. Jerome H., director, Illinois Drug Abuse Program, curriculum

vitae 236

EXHIBIT NO. 13 (a) THROUGH (C)'

Page
GoUance, Dr. Harvey, associate director, Beth Israel Medical Center:

(a) Article entitled "Methadone Maintenance Treatment Program". _ 249

(b) Letter dated May 7, 1971, to Chris Nolde, associate counsel,
Select Committee on Crime 253

(c) Letter dated Nov. 11, 1970, to Dr. Vincent P. Dole, Rockefeller
University from Carlos Y. Benavides, Jr., assistant district
attorney, Laredo, Tex 254

EXHIBIT NO. 14 (a) THROUGH (g)

Casriel Dr. Daniel H., director, AREBA (Accelerated Reeducation of
Emotions, Behavior, and Attitudes) :

(a) Article entitled "The Case Against Methadone" 296

(h) Article entitled "Casriel Institute of Group Dynamics, New

York, N.Y." (discussion of Dr. Revici paper on Perse) 302

Peer Treatment in the Casriel Institute and AREBA" 311

(d) Introduction and explanation of the AREBA program 314

(e) Reprint of article from the Medical Tribune-World Wide Report

entitled "Therapy of Narcotic Addicts Sparks Psychiatric Theory". 315

(f) Article reprinted from the Sandoz Panorama entitled "The Family
Physician and the Narcotics Addict" 317

(g) Curriculum vitae 320

EXHIBIT NO. 15

Davidson, Dr. Gerald E., associate director, drug dependency clinic,
Boston Citv Hospital, study entitled "Results of Preliminary Perse
Study"....: 331

EXHIBIT NO. 16

Beaver, Dr. William T., associate professor, department of pharmacology,
Georgetown University School of Medicine and Dentistry, prepared
statement 334

EXHIBIT NO. 17 (a) THROUGH (e)

Health, Education, and Welfare, Department of:

(a) Jennings, Dr. John, Associate Commissioner for Medical Affairs,

Food and Drug Administration, prepared statement 420

(b) Edwards, Dr. Charles C, Commissioner, Food and Drug Admin-

istration, memorandum dated May 14, 1971, with attachments. 422

Health Services and Mental Health Administration, prepared
statement 430

(d) Brown, Dr. Bertram S., Director, National Insititue of Mental

Health, Health Services and Mental Health Administration,
prepared statement 469

(e) Steinfeld, Dr. Jesse L., Surgeon General, letter dated June 21,

1971, to Chairman Pepper 480

EXHIBIT NO. 18

Villarreal, Dr. Julian E., associate professor of pharmacology. University

of Michigan Medical School, prepared statement 502

EXHIBIT NO. 19

Agriculture, Department Of, N. D. Bayley, Director of Science and Educa-
tion, Office of the Secretary, letter dated July 23, 1971, to Chairman
Pepper, re thebaine 510

EXHIBIT NO. 20

Kurland, Dr. Albert A., director, Maryland State Psychiatric Research

Center, prepared statement 520

EXHIBIT NO. 21 (a) and (b)

Page

New York State Narcotic Addiction Control Commission, Howard A. Jones,
Chairman-designate :

(a) Letter dated June 22, 1971, to the committee, re summary of

New York State drug report 578

(b) Prepared statement 580

EXHIBIT NO. 22

Holton, Hon. Linwood, Governor, Commonwealth of Virginia, prepared

statement 597

EXHIBIT NO. 23

Shapp, Hon. Milton, overnor, Commonwealth of Pennsylvania, pre-
pared statement 606

EXHIBIT NO. 24

Carter, Hon. James, Governor, State of Georgia, prepared statement 612

EXHIBIT NO. 25

Brickley, Hon. James H., Lieutenant Governor, State of Michigan, pre-
pared statement 617

EXHIBIT NO. 26 (a) THROUGH (f)

Letters and statements of officials of various cities regarding problems
of drug abuse:

(a) Boston, Mass., Mayor Kevin A. White 628

(b) Detroit, Mich., Mayor Roman S. Gribbs 630

(d) New Haven, Conn., Mayor Bartholomev.' A. Guida 634

(e) Philadelphia, Pa.:

O'Neill, Joseph F., police commissioner 637

Sofer, Dr. Leon, deputy health commissioner, office of

mental health/mental retardation 638

(f) Washington, D.C., Mayor Walter E. Washington 640

EXHIBIT NO. 27

Kramer, Dr. John C, assistant professor, department of psychiatry and
human behavior, department of medical pharmacology, L^niversity
of California (Irvine), prepared statement 662

EXHIBIT NO. 28

Statement submitted on behalf of S. B. Penick & Co., Merck & Co., Inc.,

and Mallinckrodt Chemical Works 670

EXHIBIT NO. 29

Becker, Arnold, public defender, Rockland County, N.Y., statement .__ 677

EXHIBIT NO. 30

Andrews, Rev. Stanley M., Libert}' Lobby, prepared statement 679

EXHIBIT NO. 31

Benson, Dr. Richard S., letter dated August 4, 1971, to Chairman Pepper,

re transcendental meditation (with enclosures) 681

EXHIBIT NO. 32

'Copy of letter sent to drug companies by Chairman Pepper re research

concerning narcotic blockage and atagonistic drugs 690

NARCOTICS RESEARCH, REHABILITATION,
AND TREATMENT

monday, april 26, 1971

House of Representatives,
Select Committee on Crime,

Washington^ B.C.

The committee met, pursuant to notice, at 10 :05 a.m., in room 2359,
Rayburn House Office Building, Hon. Claude Pepper (chairman)
presiding.

Present: Representatives Pepper, Mann, Wiggins, Steiger, Winn,
and Keating.

Also present : Paul Perito, chief counsel ; and Michael W. Blommer,
associate chief counsel.

Chairman Pepper. The committee will come to order, please.

The House Select Committee on Crime today begins 7 days of
public hearings which will cover four separate but related areas of
narcotic addiction. We have been examining the complex problems of
drug abuse and drug dependence since our inception as a committee
on crime in May 1969. The heroin addiction crisis has reached threat-
ening proportions. Our cities are beseiged. Our suburban areas have
become infected. Even our rural areas are now feeling the shocking
effect of this malady. Drug abuse and drug dependence have become
so unmanageable that they are now responsible, both directly and
indirectly, for contributing to 50 percent of the street crime in our
Nation. While our population has increased 13 percent from 1960 to
1969, crimes against property increased 151 percent, and violent
predatory crimes increased 130 percent.

In the face of this mounting evidence of spiraling street crime, our
citizens are properly asking whether their Government is helpless,
or corrupt, or even worse, totally incapable or unwilling to deal with a
public health epidemic.

The national heroin addiction epidemic places an impossible burden
upon an overburdened criminal justice system. This heroin epidemic
forces our police to allocate their resources unequally in attempting to
stem the illicit drug traffic. Testimony taken by our committee in New
York, Washington, San Francisco, Boston, and Miami vividly dem-
onstrated the fact that prosecutors must devote an inordinate amount
of their time and staff to the investigation and prosecution of cases
which are heroin connected. Our Crime Committee investigators have
revealed that in New York, as in most of our major cities, the adminis-
tration of criminal justice has been brought to a virtual standstill be-
cause of the volume of heroin related cases. Probation officers through-
out the country have advised our investigators that they cannot begin

(1)

to cope witli the burdens imposed on their officers b}' heroin addiction
probationers. For the same reason, our prisons also are overloaded and
our detention facilities arc strained beyond imagination. How can these
institutions be expected to perform the pi-oper function of confinement,
which is rehabilitation ? Correction and rehabilitation are not only hin-
dered by the heroin epidemic, they are made virtually impossible. As a
direct result, our alleged correction process has become a myth, and
recidivism flourishes in every major city in our Nation.

The cost in terms of dollars is staggering. The cost in terms of lives
lost is appalling. Truly, the heroin addiction epidemic has become a
national tragedy.

If we attempt to compute the monetnry loss resulting from this
heroin epidemic, we must include the involuntary social costs; that
is, the cost for law enforcement and the administration of criminal
justice, the cost of production losses. Our statistical computation of the
national dollar loss due to the heroin epidemic ranges from $1.5 to $2
billion aniuially. But this staggering amount of lost dollars pales into
insignificance when we consider the loss of human life related to heroin
addiction. Dr. Milton HelpeT-n, chief medical examiner of New York
City, told our committee in June that in 1960 there were 199 narcotic-
related deaths in New York, but this figure soared to 1.006 deaths in
1969. Sadly, of the 1,006 narcotic-related deaths in 1969, 255 were teen-
agers. Heroin addiction is the leading cause of death in New York
among adolescents and young adults between the ages of 15 and 35.
The heroin death rate in New York is not typical for densely popu-
lated metropolitan areas.

In Dade County, Fla., my congressional district, 41 young people
died from heroin last year, and nine deaths have already been re-
ported as of this year.

The death rate for narcotism in Washington and Miami have at-
tested to similar growth patterns.

You may wonder why our witness list today includes three out-
standing scientists and medical clinicians but only one law enforce-
ment official. You may wonder why a committee on crime is soliciting
the views of the scientific and medical communities and not concen-
trating exclusively upon local police officials and narcotics agents.
You may wonder why this committee is vitally concerned about the
insignificant amount of Federal and State dollars devoted to research
into the development of more eflFective blockage and antagonistic
drugs, and synthetic substitutes for heroin and morphine.

It is precisely because we have taken a comprehensive view of the
national and international drug abuse and drug addiction problem
that we are today examining the capabilities of our scientific and
medical communities to deal with this national heroin epidemic.

We have for too long relied solely upon law enforcement to control
this public health menace. This is not to suggest that law enforcement
should not play a vital role in what should be a national commitment

to stem the tide of narcotic addiction arid interdict the flow of illicit
heroin into our country. However, we can no longer delude ourselves
with the thought that law enforcement alone is capable of controlling
or even substantially reducing the flow of illicit heroin into the
United States or of reducing the number of addicts daily threatening
our cities. Heroin addiction is clearly crimogenic. Information gath-
ered by our investigators leads us to conclude that a svibstantial por-
tion of our addict population must not only steal, but also deal^
in order to pay for their voracious habits. Every addict dealer is a.
walking health menace.

Dr. Robert DuPont, of the District of Columbia Narcotics Treat-
ment Administration, estimates that the average addict in the District-
gets illegal possession of $50,000 worth of goods a year to sustain his
addiction.

The mounting evidence of the growing illicit flow of heroin into
the United States compels the conclusion that we must search for new
and imaginative answers. Our scientific and technological capabilities
must be enlisted in the fight. No longer will the prosaic law enforce-
ment approaches of the past serve as guides for future congressional
conduct.

It is with this prospective that we open 7 days of heai'ings in which
we plan to explore some brave new worlds in our struggle against the
menace of a national heroin epidemic.

In January, our committee filed a heroin report with the Congress
in which we recommended that our Government advocate and nego-
tiate toward the total eradication of worldwide opium cultivation. We
are convinced of the futility of relying solely upon overburdened and
devoted customs and narcotics agents whom we have assigned tlu' im-
l)0ssible burden of policing our borders and ferreting out heroin traf-
fickers. Responsible law enforcement officials have told our committee
that the combined efforts of our dedicated Federal and State narcotic
agents result in seizures of less than 20 percent of the heroin smuggled
into our country. Even if we were to double the size of our narcotic
enforcement agencies and provide them with unlimited spending au-
thorization, we might be able to increase our seizures 100 percent and
thereby seize 40 percent of the heroin destined for the addicts' eager
veins. But what about the remaining 60 percent ? How can we possibly
expect customs agents to search the 250 million people who pass
through our borders each year ? How can we possibly and reasonably
expect the customs agents and narcotic officials to inspect the 65.310.-
807 cars and trucks, the 306,476 planes, and the 156,994 ships wiiich
entered our country last year ?

We have been told by the customs and narcotic officials that on the
ordinary size ship arriving at the Port of New York there are 30,000
places where heroin can be concealed.

On a local level, a recently concluded study by the New York State
Investigations Commission revealed that in 1970, officers of the under-

cover unit of the narcotic division of the New York City police made
7,266 buys of narcotics, and made 4,007 arrests in connection therewith.
In all of these citywide arrests made in a year's time, a total of 4.97
pounds of highly adulterated heroin was seized. The cash used by the
New York police to make these purchases totaled $91,197.50 — that is
over $1,100 an ounce for highly diluted heroin. Surely it cannot be
argued that these arrests and seizures, at a tremendous cost of man-
power and actual cash outlay, are having a significant impact in stem-
ming the tide of organized narcotic trafficking in the city of New
York.

It seems highly unlikely that the continued diligent efforts of dedi-
cated narcotics agents, on all levels, will result in a significant increase
in the rate of heroin seizures. It seems clear that if the opium poppy
continues to be cultivated legally there will inevitably be illegal traffick-
ing in the heroin derived from this poppy.

Consequently, our committee is today examining the question of
whether we really need the opium poppy. If we can supply the pain-
killing and cough-suppressing needs of our Nation by reliance upon
domestically manufactured synthetic substitutes, then this Congress
should take the lead today in banning the importation of all crude
opium. It is to this end that we will devote a portion of this hearing.

We will then hear from law enforcement experts and scientific re-
searchers about the possibility of policing such a worldwide ban. We
also want to know whether our Federal law enforcement officials
believe that this bold step would be helpful to them, not only in stem-
ming the illicit flow of heroin into the United States, but also as a
lever in bargaining with officials from opium-producing countries.

We then plan to look at the state of development of narcotic block-
age and antagonistic drugs. Our interest is not confined to methadone,
which looks promising but is also fraught with problems. Our inter-
est is also in assessing the potential of developing longer lasting block-
age drugs such as acetylmethadol, which is being used experimentally
by Dr. Jerome H. Jaffe, in Chicago. We also want to know whether the
so-called heroin antagonists are, as Dr. Stanley Yolles (former Direc-
tor of the National Institute of Mental Health) commented, the most
promising area in narcotics research. If this is true, our committee
wants to know why more adidcts are not now being treated in rehabili-
tation centers throughout the country with nonaddicting cyclazocine
and naloxone. What are the results of experiments with antagonist
drugs? Do scientists really believe that these drugs offer a viable
alternative to methadone maintenance and drug-free treatment
modalities?

Additionally, as a committee on crime, we must not only be con-
cerned with the humanitarian aspect of opiate addiction, but also the

burden that such addiction imposes upon a society threatened and
ravaged by crime directly rebated to tliis addiction. Is methadone
maintenance an efficacious method of reducing crime perpetrated by
addicts under treatment? Does methadone maintenance reduce the
illegal activity of addicts and provide a vehicle to move these addicts
back into our society ? Is methadone maintenance safe if properly
administered in a comprehensive rehabilitation program ?

Do the deaths recently attributed to methadone — we have had six
reported deaths in the last few weeks here in the District of Colimi-
bia — do the_ deaths recently attributed to methadone mean that we
must reconsider the present posture of methadone maintenance or are
these deaths a natural incident and to be expected with the rise of
methadone treatment programs? These are just some of the ques-
tions which this committee wants answered during the course of these
hearings.

"VYe also want to know whether the guidelines recently promulgated
by the Food and Drug Administration will serve as a barrier against
wrongful, negligent, and unlawful practices by some physicians who
have dispensed methadone. We want to examine the critical question
of how can methadone, an admittedly dangerous synthetic drug, best
be dispensed. "We want to know whether methadone maintenance
can truly be an effective therapeutic approach with the proper and
costly support services.

Finally, this committee intends to survey and evaluate our present
Federal and State expenditures relating to opiate research. We want
to know if new drugs are on the horizon. Certainly the scientific genius
of this country should be implored and employed to help solve this
national calamity.

It might well be that at the conclusion of these 7 days we have
raised more questions than we have answered. However, we can no
longer afford to avoid the unpleasant evidence of the geometric
growth in narcotic addiction. This tragedy, however, might well push
us into a needed national mobilization of our medical and scientific
resources to destroy the awful heroin traffic and to deal humanely
with those who suffer from it. I know I sjDeak for all the members of
this committee when I conclude by stating that this committee is
ready to make the sacrifice, financial and otherwise, which is neces-
sary to wipe out this national health epidemic.

At this time, let us place in the record a copy of House Resolution
115, introduced January 3, 1971, and approved March 9, 1971, which
created the Select Committee on Crime in the House of Representa-
tives, described its purposes, set its goals, laid its jurisdictions, and
delineated its functions.

(H. Res. 115 follows:)

92D CONGKES.S
1st J>kssion

H. RES. 1 1 5

IN TIIK IIOISK OF llKriiKSFXTATLVKS

.I.\.\i m;v -J-I. 1!)71

.Me. I'l rrii; ( I'of liiiiist'lf iind .Mr. A\'i(;(:in>) siil)inittc(l tin- r()ll()\vin<r I'esohition ;
wliii-li wiis ivIVri'i'd to tin' ("oiumittfe on Knlcs

Fi:ni!r\i;v l*.">. I'.'T!

]>r|)()ilc(l uilli ;iiii(Mi(liiiciits, ivI'eiTi'd to tlic House Ciilciidar, ami ofdorcd to

1)0 i)rir>t('d

.Mmmii !). 11)71
( 'oiisidiTi'il, ;nii(Midi'd, and ajifced lo

RESOLUTION

;i liesolred, That, effective Jamiarv o, 1971, there is

2 hereby created a select coiimiittee to he composed of eleven

3 Memher.s of the House of Kcpreseiitative.s to ))e appointed

4 \>\ \\\(' S])eaker, one of \\ii(nii he shall desijiiiate as chainnaii.

5 Any vacancy occnrrinji' in the niciuliersliip of the select
G coiiiniitlee shall he liHed in the same manner in wjiich the

7 oriuinal ai)pointment was. made.

8 )Six\ 2. The select connnittee is authorized and directed to
0 conduct a full and complete investigation ;uid study of all

10 aspects of crime affecting- the United States, including, but

11 not limited to, (1) its elements, causes, and extent ; (2) the

12 preparation, collection, and dissemination of statistics and

1 (lata; (->) the sliariiis" oF iiiloniiatioii. staiti^itics, and data

2 amoiio' law enforcement awncies, Federal. State, and local.

3 inchuling' the excliange of infoi-niation. .statistics, and data,

4 with foreign nations; (4) the adeqna(-y i»l' law enforcement
^ and the administration of justice, inchuling' constitutional is-
^ sues and prohlems pertaining thereto: (.")) the effect of crime
'^ and distnrhanccs in the metro]iolifan nrhan areas: ((>) the
^ effect, directly or indirectly, of crime on the connnerce of
^ the Nation: (7) the treatment and rchahilitation of ])ersons

^^ conxicted of crimes; (8) mcasni-es relating to the reduction..

^^ control, or prevention of crime: (11) measures relating to the

^- injpi'oxement of (A) investigation and detection of crime,

^'^ (B) law enforcement techniques, including, hut not limited

•^ to. increased cooperation among the law enforcement agen-

-^■^' cies, and (C) the efTcctive adnnnistration of justice: and

^^ (10) ineasures and progi'ams h>r increased respect for the

' ]n\y and constituted authoi'ity.

•"^ Si'.C. .'5. I'or till', pui'posc of making such in\estigations
and studies, the. conmiillee or any suhcoimnittee thereof is

a,uthori/ed to sit and act. suljject to clause 31 of rule XI of

21 • • •

the Rules of tlie House of Kepresentativcs. during the pres-

00 . ...

ent Congress at such times and places within the United

23 1 • •

States, includmg any Commonwealth or possession thereof,

wliether the House is meeting, has recessed, or has ad-

journed, and to hold such hearings and reipure, h\' suhpena

1 or odierwise, tlu' aUciKljiiicc and tcstiiiioii}- of ^iicli \vitiicsscs

12 and tlio ])r()dut'ti()n of such Ixxtks. records, correspondence,

3 menioiaiidiims, })ai)('rs, and documents, as it deems iieces-

4 'ijary. Snbpenas may l)c issued over the signature of the chair-

5 man of the connnittee or any member designated b\' him and
^ may be served liy any person designated by such chainnan

7 or member.

8 Sec. 4. The select connnittee shall report to the House as

9 .sooii as lU'acticable during the present Congress the results

10 of its investigations, hearings, and studies, together with such

11 recommendations as it deems advisable. Any such report or

12 reports which are made when the House is not in session

13 shall be filed \\ith the Clerk of the House.

Chairman Pepper. The committee is very much pleased to call at
this time Dr. Maurice H. Seevers, one of the Nation's most respected
researchers in the held of driio- abuse and drug addiction.

Dr. Seevers holds both a Ph. D. in pharmacology and an M.D. from
the University of Chicago.

In the course of his distinguished career, Dr. Seevers has served as a
research fellow in pharmacology at the Universit}- of Chicago ; an
instructor in pharmacology at Loyola of Chicago ; associate professor
of pharmacology at the University of Wisconsin; and as associate
dean of the University of Michigan Medical School. Since 1042, he
has served as professor of pharmacology and chairman of the depart-
ment of pharmacology at the University of Michigan IMedical School.

Dr. Seevers is a past president of the American Society of Pharma-
cology and Experimental Therapeutics, and has served as chairman
of the executive committee of the Federation of American Societies
of Experimental Biology.

He is a consultant to the National Research Council's Committee
on Problems of Drug Dependence ; a member of the American Medical
Association's Committee on Alcoholism and Drug Dependence: and
chairman of the American Medical Association's Committee on Re-
search on Tobacco and Health.

Dr. Seevers has served as a member of the board of scientific coun-
selors of the National Heart Institute ; the Drug Abuse Panel of the
President's Advisory Committee, "Wliite House Conference on Nar-
cotics and Drug AlDuse; and the Surgeon General's Committee on
Smoking and Health.

Dr. Seevers presently serves as the American coordinator of the
United States- Japan Cooperative Program on Drug Abuse; he is a
member of the Expert Advisory Panel on Drugs Liable To Produce
Addiction of the U.N.'s World Health Organization; and is a con-
sultant to the Minister of Health and Welfare of Japan. Dr. Seevers
was recently appointed by President Nixon to the President's Com-
mission on Marihuana and Drug Abuse.

He has served on the editorial boards of numerous scientific journals
and has received honors befitting a man of his wisdom and dedication,
including three honors from the Government of Japan.

Dr. Seevers, we are indeed honored to have you here today, and very
grateful to you for coming here.

Mr. Perito, our chief coimsel. You may inquire.

Mr. PERrro. Thank you, Mr. Chairman. Dr. Seevers, I understand
that you have a prepared statement.

STATEMENT OF DE. MAURICE H. SEEVERS, CHAIRMAN, DEPART-
MENT OF PHARMACOLOGY, UNIVERSITY OF MICHIGAN MEDICAL
SCHOOL

Dr. Seevers. I do.

Mr. Perito. Would you care to read that statement ?

Dr. Seevers. Thank you, sir.

I will address myself primarily to the question of whether it is pos-
sible to substitute synthetic drugs for horticulturally derived
substances.

60-296— 71— pt. 1 2

The question currently before your committee, the substitution of
synthetic narcotic analgesics for narcotic analgesics or their semisyn-
thetic derivatives derived from opium is not a new one. Nor has it re-
mained unanswered by competent authorities in the past. In 1951, the
Committee on Drug Addiction and Narcotics — now the Committee on
Problems of Drug Dependence — National Academy of Sciences-Na-
tional Research Council, was confronted by the following questions
by the Munitions Board (Minutes of the seventh meeting, January 15,
1951, "Bulletin of the Committee on Drug Addiction and Narcotics") :

1. What percentage of national requirements for opium derivatives could
safely be replaced by synthetics ?

2. If at some stage during a national emergency our stocks of opium should
become exhausted and irreplenishable, how serious would be the consequences
on <he public health in view of the availability of synthetic substitutes?

The Committee answered thus — this was in 1951, 20 years ago:

All uses of morphine, codeine, and other products and compounds derived from
opium for systematic relief may be replaced adequately with substitutes now
known. The only question for which a complete answer cannot be given at pres-
ent is whether or not replacement of codeine for self-medication for cough re-
lief with synthetic agents would be as safe as the use of codeine itself? An im-
mediate and intensive effort should be directed toward the answer to this ques-
tion of safety.

For several years prior to this response the Committee was be-
sieged with requests to test new synthetic analgesics for their depend-
ence liability on voluntary ex-addicts at the USPHS Hospital at Lex-
ington. This facility was then, and still is, the only place in the world
where such studies can be conducted on man.

The industrial output has always been far in excess of the capacity
of tliis clinical unit.

Having utilized the rhesus monkey as a laboratory model of mor-
phine dependence since my graduate student days in 1925, and found
this species remarkably similar to man in its response to this class of
drugs, I suggested to the committee that this animal might be utilized
as a preliminary screen to reduce the number of drugs to be tested in
man. After 3 years of development during which the results on mon-
keys were compared carefully with those obtained on humans at the
Lexington facility, satisfactory testing procedures were available.
Since that time, this monkey colony at the University of Michigan has
become a world facility. Over 800 drugs of this class have been evalu-
ated, representing the world output, including all of these Avhich have
reached the market. Some possess properties superior to those of mor-
phine. Dozens of those tested, although not profitable for marketing
at the present stage, could be used safely and effectively in man.

Tlius 20 years after the limited affirmative of the NRC Committee
the scientific answer today is an unqualified affirmative.

But other questions which relate to the practical a]:)plication of this
scientific affirmative cannot be answered with such precision and as-
surance. Whereas I make no claim to expertise in all of these areas, I
have been involved on the scene over the last 30 3'ears, and sor.ie com-
ments may be pertinent. The elementary question, of course, is two-
pronged. ,.,j(,,

One aspect is, would the total elimination of quota production by
U.N.-recognizcd producing countries prevent the smuggling of non-

quota production from unrecognized countries? The second aspect,
would it be possible to control illicit production or snuiggling of syn-
thetics when it is currently impossible to control heroin ?

The answer to these two questions is clearly in thenegative without
international cooperation, a most uncertain probability in view of the
strong economic factors involved. May I remind you that the 10th
:session of the Economic and Social Council of the United Nations in
1956 came within one vote of adopting a resolution which would have
prohibited the production of synthetic narcotics. This action was of
such great concern to Commissioner Anslinger that he asked me to
write a paper on the subject. This paper was entitled "Medical Per-
spectives on International Control of Synthetic Narcotics." This arti-
cle raised the ire of representatives of the producing and manufactur-
ing nations, especially France, Turkey, Yugoslavia, and India. They
objected to many of the statements made in this article and for many
reasons but especially the following :

On the contrary, the scientific and medical advances in the synthetic and nar-
cotic field have been so rapid that even today very few natural products are in-
dispensable to the public health. The evidence in favor of the "synthetics" is so
impressive when subjected to comparative analysis that the author is tempted
to predict that the day is not far distant when the Commission will be confronted
with resolutions which would propose to abolish forever the cultivation and
production of all "horticulturally derived" narcotics.

Probably you have heard the following statistics but to refresh your
minds: 163 tons of morphine were manufactured legally in 1969. Ap-
proximately 90 percent of this was converted into codeine. Codeine,
although present naturally in opium, is present in such small amounts
that it is not commercially practical to obtain codeine without convert-
ing it from morphine.

This quantity of morphine was produced from 1,219 tons of opium
production and 28.274 tons of poppy straw. This was the licit produc-
tion of opium. It is controlled by the International Control Board
of the United Nations. Almost three-fourths of the total, 864 tons, was
produced by India. The second largest producer was the U.S.S.R., 217
tons ; the third largest, Turkey, with a production of 117 tons, less than
one-tenth of the total. The combined production of Iran, Pakistan,
Japan, and Yugoslavia was only 16.7 tons. If the assumption is correct,
that most of the smuggled heroin which comes into the United States
is derived from licit opium production, then it is clear that licit pro-
duction greatly exceeds legitimate medical needs.

The 1970 report of the International Narcotics Control Board of the
United Nations which furnished the above figures also contained the
following statement :

Yet if leakages from licit production could be virtually extinguished, smugglers
would still be able to have recourse to opium which is produced illegally or be-
yond Government control. There are now extensive areas of such production
and it is essential that, side by side with reinforcing monopoly controls over
licit production, major efforts should be made to eliminate poppy cultivation in
these areas. The regions chiefly involved are situated in Afghanistan, Burma,
Laos, and Thailand ; and there is also some production in parts of Latin
America.

Other questions must be dealt with. In my opinion, placing restric-
tions on natural narcotic analgesics would inspire massive resistance
by organized medicine and the allied professions. Having served on

a variety of committees of the American Medical Association dealing
with druss for over 20 vears, I am fully aware that physicians are
extremely conservative about drug therapy. Codeine, for example,
ranks high on the list of "most prescribed" drugs for the relief ot
cough and minor pains. It is a constituent of many mixtures which
are "prescribed for a varietv of sedative and antispasmodic effects.

Whereas we do have effective substitutes for codeine which are
known to be safe, they have made relatively little inroads in the pre-
scribing of codine. Furthermore, they do not substitute for codeine in
all respects, particularly since they lack its analgesic and mild sedative
properties. Relative costs, although not a compelling factor, must be
considered. Tax-free morphine is now one of the cheapest compounds
available to medicine today.

The paramount question then which confronts you, in my opinion.
is not whether synthetics will substitute for "horticulturally derived"
narcotics but rather whether outlawing the latter in favor of synthetics
will accomplish the objectives of significantly diminishing abuse of
all narcotic analgesics or, in fact, of even heroin itself.

I say this because of several international situations. I just returned
from Japan last week where I consulted with the Minister of Health.
They know exactly how most of the heroin and opium arrive in Japan,
largely down the Mekong River from the countries which I mentioned
earlier, transshipped through Macao in Hong Kong. From there it
is smuggled into their many ports, some by air, but mostly by sea to
Kobe and Yokohama, et cetera.

The Japanese have done a good job of heroin control. In 1964, the
Japanese had a sharp rise in heroin abuse. They make an all-out effort
to control this. They have available to them the facilities which I
doubt are available in the United States. In the first place, when they
say an all-out Government effort they really mean it. This goes from
the Prime Minister on down. In the last 4 or 5 years they have helcl
several thousand public meetings all over Japan in which governors,
states, mayors, even the Prime Minister participate. These are usually
held in theaters or a public auditorium and may be attended by as
many as 3,000 or 4,000 people. The hazards of drug addiction are
graphically portrayed.

Furthermore, radio, television, newspapers, and other communica-
tion media have made an all-out campaign against heroin.

One of the things which I believe contributes significantly to their
success is the fact that Japan has attacked one drug at a time rather
than to try to hit the whole area of drug abuse. This goes back to 1955
when they had the world's largest epidemic of stimulant drug abuse.
In that year there were 55,000 arrests of methamphetamine abusers.
Two years later they had reduced this by strong countermeasures to a
level of about a thousand arrests. This is the only extensive epidemic
of drug abuse, with which I am familiar, in the world that has been
controlled in such a short time. They later did a similar job of con-
trolling heroin.

One of the situations involves different attitudes toward authority.
In Japan, when an expert goes on television, such as a professor in 'a
major university, people listen to him. I am certain this rarely occurs

in this country. This raises the question whether we really have the
capabilities of adopting successfully this type of approach.

But the Japanese have their problems as well. I bring this in inci-
dentally because it doesn't bear on your major thrust but it is a drug
abuse problem which must be dealt with.

Last year, Japan had 40,000 arrests for glue sniffing, with 200 deaths.
That is one kind of substance which is almost impossible to control.
To do so, we would have to control all sales from paint stores and pur-
veyors of more than 50 related solvents. Lacquer thinner is used exten-
sively in Japan by teenagers 16, 18 years old. So Japan is not without
her problems, but they have done a remarkably good job in controlling
amphetamines and heroin addiction. I was told by the Ministry that it
liacl been reduced to a level where they though it was probably impossi-
ble to reduce it further. I think this is important — to recognize that
control will never be absolute.

Chairman Pepper. Mr. Perito, any questions ?

Mr. Perito, Dr. See vers, I had the opportunity to look at your lab-
orator3^ The committee has not had that unique opportunity.

I wonder if you could kindly explain to the committee exactly what
is being done in your primate laboratory and how that laboratory is
financed ?

Dr. Seevers. This laboratory has been in operation for 20 years. As
I indicated — we have tested during this time some 800 drugs. This test-
ing procedure started about 1953. We set it up originally on an entirely
objective basis and it has always remained so. Dr. Nathan Eddy, who
is here in the room, has been a long time collaborator on the project. He
received these drugs on a confidential basis from industry. This facil-
ity has been available to those who wish to submit for testing. Dr. Eddy
sent them to our laboratory by code number so that we do not know
the identity of the supplier.

Once the tests have been made the information is channeled back
to Dr. Eddy and he informs the manufacturer.

Until about 5 years ago, our testing procedure involved primarily
drugs which would substitute for morphine or for heroin. In other
words, we were looking for a drug which was superior to morphine
in the sense it reduced respiratory depression, less side effects, less tol-
erance development, and less what we call, in general terms, addiction
liability, the capacity to produce physical dependence.

We tested many compounds for 15 years and didn't find any that
would fulfill most of these qualifications. Wlien it was discovered that
some of the antagonists, which I understand you are going to consider
later, also possessed pain-relieving properties, somewhat like mor-
phine, and yet did not produce physical dependence or lead to addic-
tion, then a new concept was born. Since that time we have tested a
hundred or more antagonists. We have done this with the objective of
finding a substance which would still be useful as a pain reliever but
did not have a capacity to produce physical dependence. I understand
that is a class of drug that you intend to explore.

We maintain a colony of around a hundred monkeys. They receive
an injection of morphine every 6 hours, day and night, right around
the clock, 7 days a week. When we want to test a new drug we simply
substitute for the morphine which they ordinarily receive. If this drug

suppresses signs of abstinence we then can qiiantitate this in a rough
way and say this drug has morphine-like properties. This has been a
A^^ery useful test.

The number of drugs that have gone to Lexington during this
period for test — and they were sent only to Lexington if they possessed
some special propeities that were superior to morphine — I would
guess, maybe, is in the order of 40. I am not certain about the exact
number. The facility at Lexington has never had the capacity to test
more than six or eight drugs in a year.

The ultimate test, of course, is whether the effect in man is desirable
or undesirable. Monkeys are not men, but close enough to it that it has
been a very useful screen. We hope to continue it.

I feel certain that the direction which the research is taking today,
moving to find a compound of antagonist type, ultimately will be suc-
cessful. We have some good compounds now. Unfortunately, they are
too short acting and have to be administered too often to fulfill the
practical requirements as substitutes.

This class of drugs, incidentally, acts entirely opposite to metha-
done. ]\Iethadone simply suppresses and acts like heroin. These new
drugs antagonize heroin and create a situation so that an individual
taking the antagonist can take the heroin without anv effect on him.
In fact, in proper amounts, it completely wipes out any effects of
heroin. In the long run, this is an area where money could be well
spent. I think it is possible to find techniques to make available for
practical use, substances that we currently have available.

Many other antagonists have been screened in our laborator}^ which
are potential candidates for this type of action. But they have been
of no particular interest to the manufacturers, so they were just
dropped after testing. But a careful review of all antagonists that have
been studied in the laboratory might uncover some longer acting com-
pounds that might be useful.

Dr. Eddy, I run sure, will speak to this point, because he has been
the one that has channeled the compounds to our department and can
look at the problem with perspective.

Chairman Pepper. Doctor, you do think it is within the realm of
feasibility to develop an antagonistic drug which for all practical
purposes immunizes the addict against the euphoria th.at he ordinarily
gets from taking heroin ?

Dr. Seevers. I think so. Of course, one problem that you must recog-
nize—a practical problem — is whether it is possible to take heroin
addicts and force them to take this drug. This is analogous to the
methadone situation. I don't believe you will ever get beyond the
vohmteer situation where the addict says "I want to get rehabilitated
and will take the drug voluntarily." I suppose theoretically it would be
possible to force any addict to take the drug. I have doubts whether
it could be done from the enforcement point of view.

Mr. Perito. Dr. Seevers, could you explain how your laboratory is
financed ?

Dr. Seevers. W^ll, up until recently the National Research Council
Committee of the Problems of Drug Dependence had collected money
from a wide variety of industrial groups. This is, I believe, the only
granting agency in the National Eesearch Council. They have col-
lected this money and have used it to support our laboratory and also-

from other clinical projects of which Dr. Eddy has been largely re-
sponsible. He can outline this better than I.

What is going to happen in the future I am not certain. I believe
the Bureau of Narcotics and Dangerous Drugs is going to support
the laboratory because they need this kind of information. But this
has not been completely clarified as yet.

I will retire this year. A^^iether my successor, not yet appointed,
is amenable to carrying on this program at Michigan is not yet known.
But I am assuming that he is, because it is a well established and
on-going program. Dr. Julian Villarreal, currently in charge of the
program, I understand, will testify before your group. He is fully
capable of taking over this program and has done a beautiful job in
the last several years.

Mr. Pekito. Doctor, would it be possible for your laboratory to
develop an eflecti^'e synthetic analgesic which does not have addiction
liability ^

Dr. Seevers. Well, none of these antagonists have significant ad-
diction liability. This is their advantage, of course. They do not evoke
the cellular changes in the brain which is responsible for the phenom-
ena of physical dependence. We have compounds at the present time
that can be administered chronically and they do not produce physi-
cal dependence.

I am not quite sanguine enough to say that we could develop a eom-
pound that, if it has any subjective effects, would not be abused by
some persons. We have on the market a substance of this type now
which does not produce significant physical dependence: pentazocine.
I'his compound has shown some small abuse. The number of people who
will abuse this drug which does not produce subjective effects is very
small. I think if we can reduce abuse to a minimal level, it is probably
the best we can ever expect to do.

Chairman Pepper. Have you had any deaths from the use of pen-
tazocine ?

Dr. Seevers. Not to my knowledge. There have been a few re-
ported cases of drug dependence.

Mr. Perito. Directing attention to your statement about synthetic
substitutes for codeines; do we now have a single drug which will
effectively substitute for codeine or do we have to use a combination
of drugs ?

Dr. Seevers. Well, we have a compound which is a little more
]3otent: dihydrocodeinong. This has been used but since it is more
potent, it is more subject to abuse. But it is not entirely synthetic.

The search for a codeine substitute has been one of the primary
aims of industry in the last decade. It is easy enough to find substi-
tutes for morphine because we have got a Avhole list of them. But
those, that hPvVe sufficiently low potency, that they could be used as
codeine is used, with minimal addiction potential, is something we
have not quite achieved.

Chairman Pepper. Just one question. Doctor, how do you think we
can best induce organized medicine to accept a synthetic substitute
for morphine and codeine ?

Dr. Seevers. I don't think we will have any trouble with morphine.
The problem would be with codeine because it is so widely used. In
fact, the amount of morphine used in this country is very small com-
pared to the use of Demerol or other synthetics. The vast bulk of

strong narcotic use is ^Yith drugs other than morphine at the present
time.

Chairman Pepper. Well, we expect to contact and elicit a response
from the American Medical Association on this matter.

(The correspondence referred to above follows :)

[Exhibit No. 1]

American Medical Association,

Chicago, III., July 9, 1911.
Mr. Pattl L. Pekito,

Chief Counsel, Select Committee on Crime, House of Representatives,
Congress of the United States, Washington, B.C.

Dear Mr. Perito: This is in response to your letter requesting our opinion
concerning the substitutability of synthetic drugs for codeine and morphine. At-
tached to this letter is a brief review of various available synthetic drugs. As you
will note from the conclusions stated therein, it is our opinion that at the present
time no drug is fully satisfactory as a substitute for morphine or codeine.

We indeed appreciate the concern of the committee in its efforts to find a
means of curtailing the drug abiise problem prevalent today, and I want to assure
you that the medical profession is also desirous of attaining this goal. We do
not believe, however, that removing moTphine and codeine from the physicians'
drug armamentarium is an appropriate remedy. We strongly recommend that
these drugs should remain available to physicians so that their patients will not
be deprived of the valuable benefits of these drugs.

Thank you for the opportunity of providing our views, and we would appreciate
this letter and memorandum being included in the record of your hearings. If we
can be of further assistance to the committee, we shall be pleased to do so.
Sincerely,

Richard S. Wilbur, M.D.
[Attachment]

MORPHINE substitutes

Thousands of compounds have been synthesized and tested in the search for
a substitute for morphine. In addition to analgesic potency, this search has
focused on lack of addiction liability as a primary objective. To date, these efforts
have not been completely successful, although some advances have been made.

At the present time, nine strong analgesics, that are prepared synthetically (i.e.,
not derived from opium) are available on the market. These are :

1. Levorphanol Tartrate (Levo-Dromoran),

2. Methadone Hydrochloride (Dolophine).

3. Meperidine Hydrochloride (Demerol).

4. Pentazocine (Talwin).

5. Alphoprodine Hydrochloride (Nisentil).

6. Anileridine Phosphate (Leritine).

7. PiminO'dine Esylate (Alvodine).

8. Fentanyl (Sublimaze).

9. Methotrimeprazine (Levoprome).

Meperidine was the first of this group to be introduced and although earlier
it was thought to be nonaddicting. later it was found to have an addiction
liability approaching that of morphine. Nevertheless, it is the most widely used
of the strong analgesics. This may suggest that it is capable of substituting for
morphine in many cases ; however, it is recognized that meperidine Is not an
adequate sub.stitute in certain ca.ses, e.g., acute myocardial infarction.

Several of the available compounds are chemically related to meperidine, drug
numbers 5-8 in the above list. These were prepared in the attempt to improve
on the properties of meperidine. The actions of these drugs are generally similar
to those of meperidine, and although each has individual characteristics, which
limits its use in certain conditions, none is superior to meperidine, and like it
none of these would be an adequate substitute for morphine in all cases.

Both levorphanol tartrate (Levo-Dromoran) No. 1 and methadone hydro-
chloride (Dolophine) No. 2, are effective strong analgesics and have other
properties in common with morphine, including addiction liability ; however, in

practice, experience has indicated that neither would meet the requirepients in
all cases of an adequate morphine substitute.

The newest member of this group is No. 4 pentazocine (Talwin). It is the
only one with a low addiction potential, being less than that of codeine ; thus,
it is not subject to the controls of the narcotic laws. Although pentazocine is an
effective strong analgesic, as with all other drugs in this group, in certain cases,
morphine would be preferable. Additional compai-ative studies are necessary to
fully evaluate the potential use of this new drug, particularly in relation to
the older drugs.

Compound 9, methotrimeprazine (Levoprome), differs chemically from all
others of this group, being a phenothiazine derivative and related to the anti-
psychotic group of drugs. Although it does have strong analgesic properties,
its side effects of marked sedation and hypotension greatly limit its uses and
would prevent it from being an daequate substitute for morphine.

Most controlled studies with these drugs have been conducted to determine
equivalent analgesic potencies (i.e., milligram dosage), and have been carried
out in only a few types of pain, e.g., postoperative, cancer. Their broader use-
fulness in a variety of painful conditions has been determined by clinical
experience.

On the basis of this evidence it is concluded that, taken as a whole, the
group of available strong analgesics could be substituted for morphine in some
cases ; however, no single agent of this group is capable of substituting alone
for morphine. At present, evidence from experimental studies are not available
to define the preferred drug in each case. Many additional comparative studies
and further experience are necessary, particularly with newer agents like
pentazocine, to determine their ultimate efiicacy in various conditions. Further-
more, there are certain situations, e.g., acute myocardial infarction, adjunct
to anesthesia in cardiac surgery, pulmonary edema of heart failure, certain
cancer patients, in which none of the synthetic analgesics are capable of satis-
factorily replacing morphine.

CODEINE SUBSTITUTES

To act as a satisfactory substitute for codeine, a drug would need to have
the following properties :

1. Analgesic activity.

2. Antitussive activity.

3. Oral effectiveness.

4. Low addiction potential.

Of the presently available drugs none possesses all of these properties; how-
ever, it is not necessary for a comiwund to have both analgesic and antitussive
properties to be useful. Those drugs that have one or more of these properties
are considered individually below from the standpoint of a potential codeine
substitute.

Propoxyphene (Darvon) is an orally effective analgesic but it is less potent
than codeine and would not provide pain relief comparable to codeine in many
cases. Propoxyphene has low addictive liability but no antitussive activity.

Pentazocine (Talwin) lacks antitussive activity but possesses the other three
properties necessary to substitute for codeine. However, insuflBcient compara-
tive data are presently available to fully evaluate its potential as a substitute
for codeine as an oral analgesic.

Several agents are marketed as antitussive agents : these are orally effective
and have no or low addiction potential. The most widely used of this group is
dextromethorphan. Although it and the others of this group may be adequate
for relief of the milder types of cough, i.e.. associated with the common upper
respiratory infections, they would be inadequate for severe cough. For use
in this situation, a strong analgesic with antitussive activity such as methadone
may be required, but this drug has a greater addiction liability than codeine.

In conclusion, no other single drug has all the properties of codeine : thus,
none would be a satisfactory substitute. That other drugs have some of the
properties of codeine is recognized, but an adequate substitute for codeine's
use either as an analgesic or antitussive is not available at present.

NARCOTIC ANTAGONISTS

The use of the narcotic antagonists in addition to morphine and codeine
would be affected by a ban on opium and opium derivatives. Two of the three

available narcotic antagonists are prepared from opium derivatives. These
are nalorphine (Nalline) and naloxone (Narcan), the other, levallorphan (Lor-
phan) is prepared synthetically. The properties and uses of nalophine and leval-
lorphan are similar and the latter could substitute for the former. However,
the actions of naloxone differ from those of the other two agents and is con-
sidered the drug of choice in treatment of overdosage of a narcotic. Even more
significant are the studies showing that naloxone has promise in the treatment
of heroin addiction : thus, to ban the source of this drug would deprive the
medical profession of a useful drug.

Cliairman Pepper. Mr. Mann, have you a question ?

Mr. Maxx. I am very much interested in tlie action of the Economic
and Social Council of the United Nations in almost outlawino- syn-
thetic narcotics. You imply here that the economic factor was the main
factor involved. What other motivating factors do you see in that
almost-action?

Dr. Seevers. Well, I don't really know. This got doAvn to a l^attle
between the producing and manufacturing nations and those that were
most interested in the synthetics. I don't know of any other, except
traditional. Many of these changes have been in this business for a long
time. Change would be resented in countries where producing has been
going on for a long time. There is a manpower problem as well as
substitution — finding some crop that would substitute for opium.

Mr. Mann. Do you think the medical community is prepared for
the legislative outlawing of morphine ?

Dr. Sefa'ers. I don't believe so. Although morphine, itself, isn't used
so much, I think the biggest rebellion is codeine. The reason I say that,
is because we have had a somewhat analogous situation with amphet-
amines. Amphetamines as a chass of drugs are, in my opinion, the most
dangerous drugs of all available for abuse. We know from a practical
point of view that the production of amphetamines greatly exceeds any
legitimate medical need. But if you pose this question to orgnnized
medicine, which w^e have had occasion to do, even in our committee —
I attended a meeting of the AMA committee in Chicago on Saturday
of last week — even among the committee there are questions as to
whether we could get along without these. I personally think we could.

But you will not find a consensus on these matters.

Chairman Pepper. Excuse me. Will the gentleman yield right at that
point ?

]Mr. Mann. Yes, sir.

Chairman Pepper. Doctor, this committee last year offered an amend-
ment in the House, which was later adopted by the Senate, proposing
that there be a production quota system for amphetamines imposed
by the Department of Justice on the recommendation of tlie Depart-
nient of Health, Education, and Welfare. Do you think that was a
l^roDer nroposal ?

Dr. Seevers. Well, it is in the right direction. I am not sure whether
it would accomplish the objective you seek.

The only country that has really been successful in controlling am-
phetamines, as I mentioned earlier, is Japan. Sweden has also adopted
a complete ban in the sense that even a medical use is restricted to a
few speci-^lists. Three of the Australian states have done this recently.
These nations have all done it in response to a rising and hazardous
abtise problem with amphetamines.

19.

I think a quota would be better than nothing, but I am not sure this
would really solve the problem.

Chairman Pepper. Mr. Mami, I interrupted you.

Mr. IVLvNN. No further question.

Chairman Pepper. Mr. Wiggins ?

Mr. Wiggins. Doctor, if Congress should ban the importation of
morphine, should that law have an immediate effective date or should
it have a delayed application ?

Dr. Seevters. Well, off the top of my head, I would say that time is
not very important. It might be delayed long enough to work out some
alternative, but I don't see that much would be gained by delay, except
possibly the codeine problem.

]\Ir. WiGGixs. Yes. You indicated that substitutes for morphine are
available. Are they available in sufficient commercial quantities to
meet the necessary commercial need or should the industry be per-
mitted a period of time to get into that kind of production?

Dr. Seevers. I think that would probably be wise, but we have
enough variety of these compounds of synthetic origin at the present
time that I don't think we would have any significant shortage, if
there was a reasonable time.

Mr. Wiggins. Are those synthetic substitutes typically manufac-
tured in the United States ?

Dr. Seevers. They are. The principal one is sold under the commer-
cial name of Demerol. I don't know what the current total consump-
tion or total use of this substance is in the United States, but at one
time about 50 percent of the strong analgesic was done with this drug.
It is comparatively simple to produce. I don't think there would be a
serious problem.

Mr. Wiggins. If Congress should enact a statute prohibiting the
importation of morphine could you suggest any exce]:)tion we should
make to that statute ?

Dr. Seevers. Not really.

Mr. Wiggins. Oft'hand, it occurs to me that you would like to con-
tinue your scientific studies and others doubtless would too.

Dr. Seevers. I think this could be done and it would be necessary.
Morphine is still used as a standard by which we compare all other
drugs. I think a certain amount of research should be carried on. But
as far as general medical use is concerned, I can't think, offhand, of
exceptions for medical use.

Mr. Wiggins. Is it your feeling that if we excepted necessary sci-
entific research we could impose an absolute ban on the importation
of morphine ?

Dr. Seevers. It would be possible. I am not sure it will solve your
problem.

Mr. Wiggins. Are the medical consequences tolerable ?

Dr. Seevers. From a medical point of view, I think the answer is
yes. _ ; '

Mr. Wiggins. That is all, Mr. Chairman.

Chairman Pepper. Mr. Steiger ?

Mr. Steiger. Thank you, Mr. Chairman.

Doctor, did Japan treat a marihuana problem? I guess first, do
they have a marihuana problem, and if they did, did they treat it?

Dr. Seevers. They have a rising marihuana problem. They have
never had much abuse of marihuana in Japan, although it grows wild
all over Japan. But they have become concerned about it now to the
point where one of the people in the Ministry said they are thinking
about cutting it off at the root right now, which implied there would
be stricter penalties rather than lesser penalties.

A good bit of this problem has been brought back into Japan by
returning American servicemen who are there for recreation. The
Ministry is frank enough to say this, but abuse of marihuana is also
spreading now to the younger people, and there have been a consider-
able number of seizures of smuggled hashish. Some of it is smuggled
in from Korea and other areas, and also from Vietnam. So they have
had an increasing number of users in the last couple of years.

Mr. Steiger. It is illegal ?

Dr. Seevers. It is illegal.

Mr. Steiger. Have we developed, or is there any research which
points to the potential development of any oral antagonists at this
point? They are all injected ?

Dr. Seevers. Practically all of them are injected. We have some that
can be used. The trouble with these antagonists, and this has been the
real problem, is that they produce unpleasant subjective responses,
much like the hallucinogens. Individuals have weird dreams, and
weird thoughts, and the like. This has been one of the principal ob-
jections to the use of the antagonist class of drugs.

Mr. Steiger. I should think that would help sell them.

Dr. Seevers. These effects are not sufficiently pleasant. Most of
them are the type of perceptive distortions that they leally don't want.

Mr. Steiger. Doctor, to your knowledge, how long have ampheta-
mines been in use medically, not the illegal use or the abusive use,
but how long have amphetamines been in use ?

Dr. Seevers. It is back to the early 1930's as I recall.

Mr. Steiger. That long?

Dr. Seevers. Yes.

Mr. Steiger. Do you know if our military still issues the morj^hine
ampules they used to issue to people in the field, or do we use Dem-
erol, or one of these others ?

Dr. Seevers. I don't know what the present state of the military
is in this respect.

Mr. Steiger. Thank you, Doctor.

Chairman Pepper. Mr. Winn ?

Mr. Winn. Thank you, Mr. Chairman.

Doctor, on page 6 you say : "Whereas we do have effective substitutes
for codeine which are safe, they have made relatively little inroads
in the prescribing of codeine."

yiy question is why ?

Dr. Seevers. I suppose it is natural conservatism of medicine.
Codeine has always been known traditionally as the weak analgesic.
It has become, by general use, to be a constituent of many mixture?
in small amounts, and medicine is one of the most conservative
professions.

If a drug gets off on the wrong foot, medicine just looses interest
in it. I refer to a compound we are all familiar with today, methadone.

When methadone was first introduced into the field by Lilly & Co.
it was introduced under the trade name of Dolophine. They thouojht
the drug was much more potent than it actually is. Dolophine was
introduced on a 3 -milligram dose basis whereas we know the drug
has about the same potency as morphine, and the average dose is 10 mil-
ligrams. Dolophine fell flat. If Lilly had introduced it at a 10-milli-
gram dose we might have had methadone substituting for morphme.

Methadone is one of the drugs that can satisfactorily substitute
for morphine.

Mr. Winn. How many years ago did Lilly come out with that, sir?

Dr. Seevers. That was the midfifties, as I recall, just around the
midfifties.

Mr. Winn. Would you encourage the pharmaceutical houses to get
a press campaign or campaign put together so that they can use the
substitutes for codeine ?

Dr. Seevers. That is a $64 question. I don't know whether I could
give an answer to that.

Mr. Winn. Well, I am saying do you think it would be wise to do
that.

Dr. Seevers. For them to initiate a campaign ?

Mr. Winn. Yes.

Dr. See\^rs. I don't know who would do the initiating, whether the
competitors would initiate or whether producers would do the initiat-
ing. I doubt the practicality.

Mr. Winn. Thank you, Mr. Chairman.

Chairman Pepper. ^Ir. Keating?

Mr. Keating. No questions, Mr. Chairman.

Chairman Pepper. Doctor, two questions. One, this committee has
had testimony from many sources that there are some 8 billion amphet-
amines produced and distributed in this country every year, and we
have been advised, as has the Committee on Interstate and Foreign
Commerce, Subcommittee on Health, that about half of those go into
the black market. Would you tell us what, in your opinion, is the
medical need, if any, for amphetamines in this country ?

Dr. Seevers. In my opinion the need is relatively small. I think this
is a concensus of most people who reviewed the problem. The biggest
use is in the treatment of obesity. At best, this use can be said to only
temporarily be effective. The reason for this is that tolerance develops
to its continued exposure. Bigger and bigger doses are necessary. With
susceptible individuals, but not in all cases, they are likely to become
dependent upon it.

Chairman Pepper. Would you put the need in hundreds, or thou-
sands, or millions ?

Dr. Seevers. Compared to 8 billion ?

Chairman Pepper. Yes.

Dr. Seevers. Well, that is pretty difficult. The only thing I can say
is that as far as I can determine, in Japan, Sweden, and the three
Australian States, medicine hasn't been hurt very badly.

Chairman Pepper. You would say the medical need is small ?
'' Dr. Seevers. Comparatively small.

Chairman Pepper. One other question. You have spoken about the
probable reluctance or probable tardiness of the medical profession in
accepting these synthetic substitutes for morphine and codeine. We all

recogrnize vre professional people are reluctant to change from a habit
or course that we have been foUowinir. But would it te desirable to put
in perspective the necessity of balancin<r the harm that this country
derives from the abuse of these drusrs, the heroin that is smugorled into
this comitry, the terrible cost in lives and other expenditures as distin-
guished from the inconvenience or perhaps some of the imperfection
in the use of these substitutes? Would it be desirable for the medical
profession to balance those two interests in making this decision?

Dr. Seevers. I think the answer to that question is a tangential one.
You would have to sell the profession on the notion that doing this
would accomplish the objectives that you seek. In other words, when we
have so many synthetic drugs available, if there is a market, for ex-
ample, suppose you abolish illegal heroin or illegal niorphine or wipe
out all morphine, we know that there are many places in the world that
have no respect for patents, they can make these synthetic compounds
with relative simplicity and they are equally subject to abuse. I think
the real question is whether you'^simply replace one bad situation with
another one.

I think it would be necessary to convince the profession as a whole
that the objectives that you seek would be accomplished.

Chairman Pepper. Doctor, we are profoundly grateful to you for
bringing your knowledge and experience to the benefit of this com-
mittee and helping our Congress and country try to find some solution
to this terrible narcotics problem.

I think counsel wants to put in the record your original finding
here.

Mr. Perito. Mr. Chairman, may we include in the record the cur-
riculum vitae of Dr. Seevers ?

Chairman Pepper. Without objection, it will be so received.

(Dr. Seever's curriculum vitae follows:)

[Exhibit No. 2]

Curriculum Vitae of Dr. Maurice H. Seevers, Chairman, Department of
Pharmacology, University op Michigan Medical School

Date of birth, October 3, 1901, Topeka, Kans.
Education :

Washburn College (Topeka. Kans.), 1920-1924 (A.B.)
University of Chicago, 1924-1928 (Ph. D., pharmacology)
University of Chicago (Rush Medical), (4 year certificate) 19.30; (M.D.)
1932
Internship, University of Wisconsin General Hospital, 1930-1932
Appointments :

Research fellow, pharmacology, Chicago, 1926-1928
Instructor, pharmacology, Loyola (Chicago), 1929
Assistant professor, pharmacology, Wisconsin, 1930-1934
Associate professor, pharmacology, Wisconsin. 1934-1942
Visiting associate professor, pharmacology (summer 1941), Chicago
♦Professor of pharmacology and chairman of the department of pharmacol-
ogy, the University of Michigan Medical School. 1942-
Associate dean, the University of Michigan Medical School, 1947-1950.
Memberships and committees :
♦National Research Council

Committee on Problems of Drug Dependence (formerly Committee on

Drug Addiction and Narcotics) 1946-1968: Consultant— 196&-
Subcommittee Anesthesiology (Committee on Surgery), 194»-1957

♦American Society of Pharmacology and Experimental Therapeutics, 1930-
Council, 1937; membership committee, 1942, 1943, 1944 (chairman);
president, 1946, 1947; nominating committee, 1949, 1950 (chairman)
♦American Physiological Society, 1933-

Federation of American Societies of Experimental Biology Executive

Committee, 1946, 1947 (chairman), 1948
Society for Experimental Biology and Medicine Council, 1950-1953
♦American Medical Association

Vice-chairman, Section of Experimental Medicine and Therapeutics

1951-1052
Chairman, 1952-1953

Member, Council on Drugs (formerly Council on Pharmacy and Chem-
istry) 1952-1962
* Member — Committee on Alcoholism and Drug Dei>endence — Council on

Mental Health, 1964-
♦Chairman — Committee on Research on Tobacco and Health AMA-ERF
1964-

Honorary memberships :

♦American Society of Anesthesiology.
♦Japanese Pharmacological Society.

Committees and consultantships :

Member — Board of Scientific Counselors, National Heart Institute, Na-
tional Institutes of Health, 1957-1960.

Member — Drug Abuse Panel, President's Advisory Committee — White
House Conference on Narcotic and Drug Abuse, 1962-1963.

Member — Surgeon General's Committee on Smoking and Health, Depart-
ment of Health, Education, and Welfare, 1962-1963.

Chairman — Committee on Behavioral Pharmacology — Psychopharmacology
Service Center-National Institutes of Health, 1964-1968.

♦American coordinator — U.S. Japan Cooperative Program on Drug Abuse —
National Science Foundation and Japan Society Promotion of Science,
since 1964.

♦Member — President's Commission on Marihuana and Drug Abuse, 1971-72
(established by Public Law 91-513) .

Editorial :

Board of publication trustees, American Society for Pharmacology and Ex-
perimental Therapeutics, 1948, chairman, 1949-1961.

Editorial board. Physiological Reviews, 1943-1951.

Editorial board. Proceedings Society for Experimental Biology and Medi-
cine, 1944-1959.

Editorial committee. Annual Review of Pharmacology, 1959-1962.

International :

♦WHO (United Nations) Expert Advisory Panel on Drugs Liable to Pro-
duce Addiction, 1951-

Second Medical Mission to Japan, May-June, 1951 Unitarian Service Com-
mittee and Department of the Army.

U.S. National Committee for International Union of Physiological Science,

Chairman American team— Conference on Physiologic and Pharmacologic

Basis of Anesthesiology— Japan, April-May 1956.
Consultant— Minister of Public Health of Thailand— Bangkok, May 2-17,

1959
♦Consultant, Minister of Health and Welfare of Japan, Tokyo, 1963-.

Awards :

Third Class of the Order of the Rising Sun 6f Japan, 1963.

Distinguished Service Award Washburn University Alumni Association,

1964. ^^ .„„_

Second Class— Order of the Sacred Treasure of Japan, 1967.^
Henrv Russell Lecturer— The University of Michigan, 196 (.
J Y. Dent Memorial Lecturer— Kings College-University of London, 1968.
Certificate of Commendation from Minister of State Director-Geneial,

Prime Ministers Office, Japanese Government, October 1969.

•Current appointments.

(The following letter was received for the record.)

[Exhibit No. 3]

Assistant Secretary of Defense,

Washington, D.C., June 28, 1971.
Hon. Claude Pepper,
House of Representatives,
Washington, B.C.

Dear Mr. Pepper : This is in reply to your letter of June 7 in which you re-
quested our views on the use of opium derivative drugs in the military medical
services and statistical data representing procurement and issues of these drug
items, as well as synthetic pharmaceuticals with similar effects.

"A consensus of military medical opinion on the need for opium derivative
drugs to treat casualties in the field and in hospitals." It is the consensus of
the Military Medical Departments that opiate drugs have an established place
in medical practice and cannot adequately be replaced by any other substances.
The need for opiate drugs is predicated on the pi-inciple that the highest pos-
sible quality of medical care should be rendered to military personnel and their
dependents. While it is true that there are many occasions when the synthetic
analgesic drugs would suffice, there is also a substantial number of indications
where the opiate drugs are clearly superior. For example, it has not been
demonstrated that the synthetic drugs are equal in efficacy to the opiates in
myocardial infarction, acute pulmonary edema, and in relief of pain in the
severely wounded.

"A consensus of military medical opinion on (a) the use of, and (b) the ef-
fectiveness of synthetic analgesic substitutes to treat casualties in the field and
in hospitals." The synthetic analgesics have a significant and increasing use-
fulness in treating casualties in the field and in hospitals. However, there re-
mains a substantial proportion of casualties in whom the opiate drugs are clear-
ly preferable. In addition, many of the synthetic analgesics have only a very
short period of experience with their use and it would be unwise to restrict
medical practice by relying solely on these newer compounds.

"A consensus of military medical opinion on the advisability of eliminating
opium derivative drugs and the substitution of synthetic analgesics." It would
be inadvisable to eliminate opiate drugs from medical and surgical practice. It
Is evident that the amount of opiate drugs used could be greatly curtailed by
substitution of the synthetic drugs. However, the total removal of opiates from
medical practice would result in less than optimum treatment of countless in-
dividuals having life-threatening diseases and injuries.

Statistical data representing procurements and issues of centrally managed
opium derivative drugs, as well as synthetic pharmaceuticals with similar ef-
fects, is attached as enclosure 1. This data represents the latest 4 complete fiscal
years. Data prior to fiscal year 1967 is not available. Miss Hastings of your
staff agreed to the submission reflecting this period of time.

Although most of the opium derivative drugs are procured and issued to the
military medical services by the Defense Supply Agency, larger medical facilities
locally procure nonstandard, slow moving opium derivative drugs. These facil-
ities are all registered with the Bureau of Narcotics and Dangerous Drugs.

Attached as enclosure 2 is a copy of the regulation "Safeguarding of Sensi
tive. Drug Abuse Control, and Pilferable Items of Supply" as per your request.

The Veterans' Administration does not procure these items from the Depart-
ment of Defense. The Veterans' Administration has its own procurement system
and buys these items directly from vendors.

There are no separate regulations or security precautions applicable to syn-
thetic analgesics versus opium derivatives. The governing factor in this instance
is whether the Bureau of Narcotics and Dangerous Drugs has classified the item
in one of five schedules for controlled substances. If so. security measures are
required ; however, these items are dispensed by prescription only.

I trust this information will be of assistance to you and the committee.
Sincerely,

Louis M. Roussei.ot, M.D., F.A.C.S.

25.

I'BOCUREMENT AND ISSUE DATA FOB CENTRALLY STOCKED OpIUM DERIVATIVE

Drugs and Synthetic Analgesics With Similar Effects

The information in tliis enclosure is qualified as follows :

1. Procurement quantities are indicated by the fiscal year in which contracts
w^ere awarded (or delivery orders processed). Actual delivery to DSA depots
and subsequent issue to DSA customers does not normally correspond to these
fiscal years. In addition tlo Army, Navy and Air Force units, the DSA has in-
teragency agreements to supply medical materiel directly to the following
Federal agencies : NASA, USAID, D.C. Government, U.S. Coast Guard, FAA and
GSA. Certain Army, Navy and Air Force units also supply directly to other Fed-
eral and foreign agencies. For example, the Republic of Vietnam Armed Forces
and USAID in Vietnam are supplied with medical materiel from the U.S. Army
Medical Depot in Okinawa.

2. In some cases, procurement and issue data do not appear to be related. This
can occur when items are being phased out of the distribution system or new
items are added to the armamentarium. Further, changing mobilization reserve
materiel objectives may be responsible.

3. Only those forms of propoxyphene containing at least 65mg are included.

4. Methadon is n(jt managed centrally as yet.

1967

Fiscal years —

1968

1969

1970

6505-114-8950— Codeine sulfate tablets, NF, 32 mg., 20's:

Procured by DPSC ^ 24,700

Issued to:

Army _ _ ._ 4,797

Navy 1,678

Air Force 640

IVIAP 20

Other = _.. 3

6505-114-8975— Codeine sulfate tablets, NF, 32 mg., lOO's:

Procured by DPSC 92,016

Issued to:

Army ^fek 9,525

Navy 9,420

Air Force. 9,088

MAP 9.803

Others 14,987

6505-615-8979— Codeine phosphate, USP, 1 oz. (28.35 gm.):

Procured by DPSC 2,502

Issued to:

Army 5,306

Navy - _. 1,752

Air Force 576

MAP...,. 144

Oth^ir 19

6505-864-8092— Codeine phosphate injection, USP, 30 mg.
cartridge-needle unit 1 cc, 20's:

Procured by DPSC i

Issued to:

Army.... 2,610

Navy.. 1,367

Air Force 1,071

MAP. L-. 0

Other 2 0

6505-864-8091— Codeine phosphate injection, USP, 60 mg.,
cartridge-needle unit 1 cc, 20's:

Procured by DPSC .^^..^ ic..: 4,230

Issued to: ^ ' =

Army 1,181

Navy 1,293

Air Force. 732

IVIAP . 0

Other 0

6505-929-8986— Hydromorphine, HOI injection, NF, 2 mg.
cartridge-needle unit 1 cc, 20's:

Procured by DPSC 10,200

Issued to:

Army _' 0

Navy 0

Air Force 19

MAP 0

Other 0

See footnotes at end of article.

3,638

1,818

1,454

297

203

366

126

474

3 15, 593

75,816

96,336 ..

47, 481

55, 344

14,811

8,980

9,405

8,470

9,514

10, 581

9,759

9,508

5,407

22,012

236

2,614

2,221

11,808

2,304 ..

5,016

2,043

4,111

1,126

1,312

664

1,753

2,106

1,433

109

9,600

11,430 ..

3,278

5,366

1,260

994

1,532

418

1,166

2,057

1,085

171

2,040

11,100...

1,542

1,410

840

1,482

2,009

771

882

1,211

889

14
0

59
2,520

1,483

1,160

927

586

1,274

800

750

1,196

1,440

60-296 — 71— pt. 1-

Fiscal year;

i—

1967

1968

1969

1970

6505-132-3030-Paregorlc, USP, 1 pt. (473 cc):

Procured by DPSC ' -

69,792 -.

39, 936

92, 776

3,715

5,706

3,556

424

64, 368

Issued to:

Army. - -

Navy

Air Force

25, 773
2,691
7,497

18,813
496

23, 598

4,499

6,484

4,017

339

3,960
2,618
4,658

MAP

Other 2 -

6505-129-5000— Morphine sulfate tablets, USP, 8 mg., 20's:

Procured by DPSC

7,658
168

Issued to:

Army ---

Navy -

Air Force -

MAP

Other -..- ------

6505-129-5500— Morphine sulfate tablets, USP, 16 mg., 20's:

Procured by DPSC ---

4,428

852

110

235

323

920

65 ...
21 ...
78 ...

4 ...
32 ...

Army -

Air Force - --

3,924
996
1,265
3,460
4,432

226,250 ..

663

233

793

1,772

3,181 ...

1,411 ...

318 ...

0 ...

4 ...

Other

6505-129-5517— Morphine injection, USP, 16 mg., 1.5 cc:

Prnnirori bv DPSC 1 ..

Army. _ - -

Navy - - -

Air Force -.

2,096

2,974

36, 206

2,500

258,500 ..

22, 782
11,601

6,019
12,921

1,483

25, 387

3,744

4,599

24, 805
4,057

604
6,023

949

39, 892

2,132

11,549

370

25, 193

12, 897

1,162

8,719

4,112

11.160

12,203

9,132

MAP.--.

Other' --

105
18, 000

6505-129-5518— Morphine injection, USP, 16 mg., 1.5 cc, 5's:
Procured bv DPSC

Army -

5,259
6,363

Air Force

292

MAP---

Other -

Procured bv DPSC

15,603
1,840

Army. - - -

Navy ---

Air Force

597

594

537

4,500

1,606

741

588

5,820

3,626

2,053

2,559

267

3,660

2,623

1,750

1,753

201

530

310

4,380

1,757

1,391

614

28, 335

11,737

3,592

3,257

185

9,420

3,734

2.300

2,139

178 ...
152 ...
191 ...

0 ...

3,360

1,672

973

695

5,640 ...

Other. -

6505-864-7617— Morphine injection, USP, 8 mg., cartridge-needle
unit, 1 cc, 20's:

2,500

Issued to:

Navy --

905
618
784

MAP -

146

6505-864-7618— Morphine injection, USP, 15 mg., cartridge-needle
Procured bv DPSC - ..

Issued to:

Army -

Air Force

6,133

2,138

2,978

217

10,590

4,247

2,473

2,652

3,299
2,549
3,265

MAP

Other -

141

unit, 1 cc, 20's:

4,328

Issued to:

Navy

2,816
2,515
3,020

MAP

6505-435-8477— Pentazocine lactate injection. Equivalent of 30
mg. of pentazocine, 1 cc, syringe-needle unit lO's:
I Procured bv DPSC ' .

50
5,184

Army

k\T Torce _

other 2 - -

See footnotes at end of article.

Fiscal years—

1967 1968 1969 1970^

678

19, 789

179

18, 432

669

13,281

154

276

799

6505-689-5513— Pentazocine lactate injection. Equivalent to 30
mg. of pentazocine per cc, 10 cc:

Procured by DPSC... - - - 43,200 46,656

Issued to:

Army _ .-.

Navy._ - -

Air Force - --

MAP _ ..- - --

Other

6505-477-4655— Fentanyl citrate injection. Equivalent to 0.05
mg. of fentanyl per cc, 2 cc, 12's:

Procured by DPSC _ 1,296

Issued to:

Army _

Navy - - - _

Air Force -

MAP. - _

Other -

6505-477-4667— Fentanyl citrate and droperidol injection, 5 cc,
12's:

Procured by DPSC i 1,728

Issued to:

Army.. _

Navy ___

Air Force 14

MAP

Others _ _.. _ '

6505^84-6183— Fentanyl citrate and droperidol injection, 2 cc,
12's:

Procured by DPSC _ _ _ 1,728

Issued to:

Army _ _ ___

Navy _ _

Air Force _ _._ §

MAP

Other

6505-958-2364— Propoxyphene HCI capsules, USP, 65 mg., 500's:

Procured by DPSC 35,520 28,080 18,336 17,664

Issued to:

Army 9,741 13,841 12,629 11,865

Navy 3,303 4,953 5,758 8,304

Air Force 5,255 5,719 6,821 7,248

MAP 0 44 57 92

Other.... 98 161 348 165

6505-913-7907— Propoxyphene HCI, aspirin, caffeine, and
phenacetin capsules, lOO's:

Procured by DPSC 1 10,224 3,660 500

Issued to:

Army 2,994 49 904 2 749

Navy 129 213 30 188

Air Force 33 41 116 307

MAP 0 34 60 24

Others..-. 0 524 793 2,465

6505-784-4976— Propoxyphene HCI, aspirin, caffeine, and phen-
acetin capsules, 500's:

Procured by DPSC 78,048 158,208 131,688 27,792

Issued to:

Army 31,782 68,946 71,995 29,776

Navy... 14,392 23,853 31,896 28,162

Air Force 20,399 25,837 31,928 32,927

MAP 0 441 962 985

Other... _ 653 562 2,318 840

6505-082-2651— Meperidine HCI injection, NF, 75 mg., cartridge-
needle unit, 1 cc, 20's:

Procured by DPSC 4,680 7,380 2 640

Issued to:

Army 1,313 3,178 2,298 1,938

Navy 936 716 1,587 528

Air Force. 1,195 2,045 1,694 1,354

MAP- 0 11 36 15

Other...- _ 0 1 181 84

6505-082-2652— Meperidine HCI injection, NF, 75 mg.,cartridge-
.needle unit, 1 cc.,20's:

- Procured by DPSC 1 13,200 8,730 19,200 8,820

Issued to: ■,. , ,-

Army ..AQ..'il>.:'.'iil.:: - 2,401 4,986 7,151 6,346

Navy 1,505 2,362 2,900 3,355

AirForce. ■ 2,455 2,809 3,658 4,749

MAP 0 18 6 6

Others 225 167 102 133

See footnotes at end of article.

Fiscal years-

1967 1968 1969 1970

6505-126-9375— Meperidine HCI tablets NF, 50 mg., lOO's:

Procured by DPSC 13,536 5,904 6,480 7,920

Issued to:

Army --- - 4,052

Navy..-. 2,295

Air Force ---- 2,048

MAP 1,788

Other.. - ---- ---- 631

6505-126-9360— Meperidine HCI injection NF, 50 mg., per cc, cc:

Procured by DPSC .- 93,744

Issued to:

Army -...:. 20,298

|\|avy 24,448

Air Force 17,907

MAP - 4,392

Other 3,455

6505-864-8093— Meperidine HCI injection, NF, 100 mg., car-
tridge-needle unit, 1 cc. 20's:

Procured by DPSCi 3,830

Issued to:

Army... ---. 1.920

Navy.. 1.926

Air Force 1.558

MAP 0

Other 2 2

6505-854-8094— Meperidine HCI injection, NF, 50 mg., cartridge-
needle unit, 1 cc, 20's:

Procured by DPSC ..-- 21,270

Issued to:

Army --- 4,616

Navy - 2,715

Air Force --- 3,410

MAP 0

Other 157

6505-864-8095— Meperidine NCI injection, NF, 100 mg., cartridge-
needle unit, 1 cc, 20's:

Procured by DPSC. ^p '. .- 4,200

Issued to:

Army.-.. .--- 4,243

Navy .-- .--- 3,177

Air Force 2,825

MAP .-- 30

Other - 148

6505-864-8095— Meperidine HCI injection, NF, 50 mg., cartridge-
needle unit. 1 cc, 20's:

Procured by DPSC 11,340

Issued to:

Army 765

Navy.. 615

Air Force 855

MAP

Other 2 2

1,311
1,460
1,919
1,456
38

2,862

1.573

1,956

140

1,222

1,095

1,586

1,458

352

63,720

59,184 ...

34,803

16,144

12,305

5,378

128

24, 870

13,709

8,681

165

6,892
8,977
5,228
3,696
89

3,300

12,720

4,740

2,792
754

2,152

625

2,830
1,338
2,339
1,106
224

2,060
1,011
1,657
2,555
386

13, 860

27, 840

18,180

8,846

2,825

3,963

100

150

10,873

3,167

5,146

175

9,835

3,295

6,228

190

9,300

18, 540

8,888

7,654

3,399

2,830

119

138

5,305

2,980

3,714

5,817
3,244
4,066

1
44

4,260

10,020

4,140

3,651

1,269

2,383

339

136

4,481

1,289

2,240

132

1,139

1,396

1,977

147

» The difference between quantities procured and total issued is caused by the exclusion in this tabulation of the in-
ventory on hnnd (beginning FY 1957) and the inventory required to be retained as depot stocks at the end of FY 1970.

2 Other type customers are non-DoD. In order of user magnitude: AID and Public Health about the same. Coast Guard,
State Departnient. etc.

3 Item deleted May 1, 1970, This quantity transferred to property disposal.

(Enclosure 2 was retained in the committee files.)

Chairman Pepper. Our next Tvntness is a man so eminently qnalified
to spealv on the subject of drug abuse that I could spend a good i>art
of the rest of this hearing just listing his qualifications.

The committee is pleased and honored to welcome Dr. Nathan B.
Eddy.

Dr. Eddy holds a doctor of medicine degree from the Cornell Uni-
versity Medical School and an honorary doctor of science degree
from the University of Michigan.

Dr. Eddy began his career with the practice of medicine in New
Yoi-k City in 1911. Since then, he has been an instructor of physiology
;it McGili University; an assistant professor of physiology and phar-
macology at the University of Alberta; visiting investigator at the
department of pharmacology, Cornell University Medical School;
visiting investigator and lecturer, department of physiology, the Uni-
versity of Michigan: consultant biologist in alkaloids to the U.S.
Public Health Service; principal pharmacologist. National Institutes
of Health; chief of the Section of Anal<resics, Laboratory of Chemis-
try. National Institute of Arthritis and IMetabolic Diseases of the Na-
tional Institutes of Health. The last position he held before he sup-
posedly retired in 1960. Since his retirement, he has served as a con-
sultant on narcotics to the National Institutes of Health ; the Executive
Secretary and currently Chairman of the Committee on Drug Addic-
tion and Narcotics of the Medical Division of the National Research
Council ; consultant to the Bureau of Narcotics and Dangerous Drugs;
consultant to the New York State Narcotic Addiction Control Com-
mission, and consultant to the Le Dain Commission on Nonmedical
Uses of Drugs.

Dr. Eddy is a member of numerous honorific and professional asso-
ciations and has served on countless committees concerned with drug
addition, lioth in this country and for the United Nations.

Dr. Eddy's awards, all well deserved, are legion. Some of the groups
which have honored him are the U.S. Public Plealth Service, the
World Health Organization, the Eastern Psychiatric Research Asso-
ciation, and the American Social Health Association.

Dr. Eddy has authored and coauthored more than 150 books and
articles on a variety of subjects.

'^ Dr. Eddy, with his considerable experience in pharmacology and
physiology, will testify today on the present availability of synthetic
drugs to replace morphine and codeine.

It is indeed a great honor to have you with us today, Dr. Eddy,

Mr. Perito, our chief counsel, will inquire.

Mr. Perito. Dr. Eddy, I understand you have a prepared statement.

STATEMENT OF DS. NATHAN B. EDDY, CHAIRMAN. COMMITTEE
ON PROBLEMS OF DRUG DEPENDENCE, DIVISION OF MEDICAL
SCIENCES, NATIONAL ACADEMY OF SCIENCES-NATIONAL RE-
SEARCH COUNCIL

Dr. Eddy. Mr. Chairman, I prepared a statement for the committee
which might be called a series of thumbnail sketches of potential
alternatives to morphine and codeine.

I think it would take considerable time and be repetitious of a good
deal of technical detail to read that statement. With your permission,
I would prefer to make some pertinent statements of pertinent facts
and principles and afterward elaborate, if you wish, and answer ques-
tions so far as I can on points which have not been covered.

Chairman Pepper. Proceed as you will, Dr. Eddy.

Dr. Eddy. It is a privilege indeed to be here today and speak on the
question of the replaceability of the natural opiates direct and indirect.
By direct I mean, of course, morphine and codeine which occur natu-

rally in opium. By indirect, the substances which are derived from
morphine and codeine by modification of one sort or another, such
as hydrocodone, hydromorphone, oxymorphone, oxycodone, and
heroin, which, of course, is paramount in the problems of drug
dependence.

Let me start off by saying unequivocally that the natural opiates,
direct and indirect, can be replaced by synthetic substances presently
available. I am not alone in this belief. Dr. Seevers has already so
stated and I believe Dr. Brill will concur in this opinion. Also, as
Dr. Seevers indicated, the Committee on Drug Addiction and Narcot-
ics, now the Committee on Problems of Drug Dependence of the
National Research Council, has on at least four occasions adopted
resolutions, the sense of which is the same.

Referring to the descriptions which were in the statement prepared
for the committee on specific alternates, these cover a wide range, not
so wide strictij speaking from the chemical standpoint, but a wide
range in potency when we think in terms of dosage only. There are also
some variations in the surrounding j)roperties of the various com-
pounds. We have compounds which are several times — I am talking
about compounds which are presently available on the market — we
have compounds several times more potent than morphine; levor-
phanol, for example, which is like morphine in all essential
respects and equally dependence-producing. We have phenazo-
cine, somewhat different chemically, which is also several times more
potent than morphine and shows a slightly reduced dependence poten-
tial. It has not become very popular because the difference is not as
great quantitatively as hoped in the beginning.

We also have potential substitutes which are less effective dose wise
than morphine. The most popular of these is Demerol, or meperidine,
or pethidine. It has 40 or 50 different names around the world. It is
only about one-sixth to one-eighth as potent as morphine, thinking only
of dosage. It is equally dependence-producing. As a matter of fact, it is
my personal opinion relative to its pain-relieving properties it has a
greater dependence potential than does morphine itself.

Then we have pentazocine, which is quite different from Demerol
in its chemistry and belongs to a new class of compounds to be referred
to in somewhat more detail in a moment. It is about one-fourth as
potent as morphine. It has essentially no physical dependence potential
or such physical dependence potential as it possesses is of a different
type from that of morphine. It does have subjective effects which a
few people have found to their liking, especially if they have been
abusing other drugs and there are a small number of cases of abuse of
pentazocine reported. Pentazocine is being accepted to a verj^ consider-
able extent by the medical profession: its sale is increasing and it is
proving to be a quite effective compound.

There is a difference in these compounds with respect to their rela-
tive oral and parenteral use, oral and subcutaneous or intramuscular
use. The first I mentioned, levorphanol, is equally effective by mouth
as by injection. Practically all of the others are less effective by mouth
than by injection. Ppntazocine perhaps is another exception, the range
between its oral and parenteral dose is narrower than for most of the
other compounds.

I have been involved in this problem of trying to find, or trying to
disassociate, the dependence properties and the useful pain-relieving
properties of compounds which we could use in place of morphine for
some 40 years. It has been a most frustrating effort for most of that
time until we discovered, partly by accident, as the result of a sugges-
tion I made in another connection, that certain chemical modifications
of morphine-like substances produced at the same time the ability to
relieve pain or possessed at the same time the ability to relieve pain
and the ability under some circumstances to antagonize the effects of
morphine itself. The first of them was nalorphine. Many like com-
pounds, or many compounds in this class, have been made since then,
as Dr. Seevers pointed out. These antagonists, the compounds with
antagonistic potentiality, have little or no i^hysical dependence capac-
ity. Such physical dependence capacity as they possess is of a different
type from that produced by morphine. Their subjective effects are
different and in most people are exceedingly unattractive. We call these
compounds agonist-antagonists and pentazocine is an important
example.

To reiterate, I believe that it is possible to replace the natural opiates
with synthetic substances. The question is: Is it practical? At the
present time I think the answer has to be "no," because we have to
take so many other things into account other than the mere ability
to replace one compound with another without interfering with medi-
cal practice or without damage to the patient. As a matter of fact,
we might even, with some of these substitutes, improve the conditions
with respect to the patient.

Again, the answer is "no," if we are thinking simply in terms of
saying you cannot have the natural opiates, but must use the synthetics.
We banned heroin in this country from medical practice, but that did
not ban it from the illicit market. The illicit market in heroin is still
increasing.

As I said, I have been working in this held for 40 years, hoping that
some day we could say we can get along without opium. Today we
can say that, medically, we can get along without opium, but I am
not at all sure that we should say it in just that way, without qualifi-
cation. If I may make a suggestion, I think we can say to the world
at large, the time has come wlien we should be putting every effort into
economic and technical assistance to the opium farmer so that he can
live by the production of other crops and without the production of
opium. Meanwhile, we are going to continue to study the agonist-
antagonists because I think pentazocine can be further improved upon
and we are going to continue to pursue other lines of chemical investi-
gation, which in some instances already promise compoimds which are
not antagonists but which have reduced the dependence potential.

Some people like practically every drug, or for practically every
drug there are some people who like it, no matter how adverse it
seems to most of us. We call this craving or liking a psychic depend-
ence. I am very pessimistic about our ever eliminating completely
psychic dependence. We can and we have eliminated the ability — or
produced compounds which have eliminated the ability — to produce
physical dependence. We can do something about the individuals lik-
ing for other things, like his abuse of other things, and we can improve
the situations so far as drug abuse in medical practice is concerned.

We can, I think, most helpfully go back to the source, the opium
source, and try to do more than we have done about the overproduc-
tion, especially the illicit production, of opium to reduce the availa-
bility of compounds for abuse.

Chairman Pepper. Doctor, did I understand you to say tliat you
thought we could now scientifically develop an antagonistic drug to
heroin which would give, as Dr. Seevers indicated, a relative immunity
of sensation to tlie addict in the taking of heroin ?

Dr. Eddy. We already have such compounds.

Chairman Pepper. If that could be put into mass use, then that would
to a large degree remove the desire for the taking of heroin, I ])resume,
from the addict ?

Dr. Eddy. Well, the answer isn't quite as simple as that. We can
antagonize the effects of heroin. We can prevent the individual from
getting a response to his taking of heroin. We don't necessarily, by
the same token, remove his desire to take heroin. We can prevent the
heroin from having any effect upon him, but we don't necessarily, at
the same time, prevent him from wanting to have that effect.

Chairman Pepper. ]SIr. Wiggins wishes to ask a question.

Mr, Wiggins. Doctor, I am confused. Why would a person take two
drugs that would have the net effect of taking none? I gather that
there are antnironists that neutralize heroin?

Dr. Eddy. That is right.

Mr. WiGGixs. Which has the effect of not taking heroin.

Dr. Eddy. That is right.

IVIr. WiGGixs. So why not, just in terms of the logic of it, avoid tak-
ing heroin in the first instance?

Dr. Eddy. Well, they generally do. If you can persuade them to take
the antagonist even though they want the subjective effects of the
hei^oin or another opiate. The problem is to s:ei: them to take something
v/hich they know is going to prevent them from getting the kick they
want. The people who have been put on the antagonists, they don't
necessarily take your word for it that they are not going to get any
kick out of their heroin, and they may go back and try heroin until
they find that this is futile. If they have got any sense they are going
to say, "Well, I am throwing mj^ money away." And as long as you can
keep them on the antagonist they cannot get an effect out of heroin and
hence have no reason to abuse heroin or to go out on the street and
steal televisions and cars and the rest of it to buy heroin.

So you have improved the situation from that standpoint for them
and yourself. But you have to persuade them to take the antagonist.

Chairman Pepper. Excuse me. Could you add something to that
antag'onistic drug to cause the patient to get an unfavorable reaction
if, after taking the antagonistic dnig, he took heroin ?

Dr. Eddy. Well, you can do it the other way around. If he is taking
heroin and you give him the antagonist you certainly give him an mi-
pleasant reaction. I don't know any instance wheie he necessarily gets
an unpleasant i-eaction from the heroin he attempts to take after he
has taken the antagonist. He may get an unpleasant reaction from the
antagonist itself until you stabilize him on it.

Mr. Wiggins. Does the antagonist have any effect ?

Dr. Eddy. For a person dependent on an opiate, the antagonist pve-
cipitates withdrawal symptoms, very markedly so. It is the same as if

you had taken all of the heroin or opiate away from the addict, just'
like that. He goes into withdrawal when you give him an antagonist if
he is taking an opiate.

Mr. WiGGixs. How much success are you having in getting people to
do this voluntarily ?

Dr. Eddy. Well, it hasn't been tried too widely. There are two diffi-
culties, at least. One is that the most potent antagonist we have, which
has been tried, cyclazocine, is likely to produce unpleasant reactions
when you start to administer it. Dr. Seevers referred to these. They
are quite disagreeable. You have to proceed rather cautiously with
most people to stabilize them on the cyclazocine. They, too, become tol-
erant, accustomed to the drug so that these unpleasant reactions disap-
pear and you can stabilize them, keep them in a state where they can
take cyclazocine day by day and be free from any adverse symptoms.
You have got to completeh' withdraAv them from their heroin, dis-
continue their hei'oin administration completely for several days before
you start the antagonist.

That is one drawback for that particular antagonist. The other one
which has ]:)een used to the greatest extent is naloxone, which does not
produce any unpleasant reactions at all. It is as nearly as we know, a
pure antagonist. It has no morphine-like eifects whatsoever. Cyclazo-
cine does have morphine-like effects under certain circumstances. It is a
powerful analgesic. It is on the order of 40 times more potent as an
analgesic than morphine itself. But to attain its analgesia you are liable
to produce, with a great many people, these unpleasant side reactions.
So it is not a practicable analgesic.

Xaloxone is not an analgesic at all. It only produces antagonism.
It is quite effective when injected, but it is very poorly effective by
mouth and the doses required to stabilize the individual to a state
where he would not get a reaction from taking heroin requires very
large oral doses, and the duration of action is short.

But we have other antagonists in the offering, which we ho[)e to be
able to develop, of longer duration and hopefully as effective as cycla-
zocine, without the unpleasant reactions. This is the field in which a
great deal of effort is being put at the present time. Ideally, it would
seem to me the way to go about it. Practically, as I say, the difficulty is
to 2:)ersuade the patient to begin and to continue the administration of
the antagonist; but he must, initially, give up his opiate entirely and he
must take a compound which he knows is going to prevent him from
getting any of the reactions that he has been wanting. So far as this
can be done, the program is successful.

Chairman Pepper. Doctor, Mr. Perito has a question.

Mr. Perito. Dr. Eddy, do these antagonists have an opiate base?

Dr. Eddy. No.

Mr. Perito. They do not ?

Dr. Eddy. No; not necessarily.

The original, tlie first antagonist that we are familiar with, nal-
orphine, is a modified morphine. You can make similar modifications
in various of the synthetic bases which are used as analgesics, in levor-
phanol, for example. You can make a similar substitution in levor-
phanol and get a more potent antagonist than nalorphine. You can
similarly substitute in the synthetic phenazocine the same group and
get a very powerful antagonist with very intense subjective reactions,

so intense that we haven't done very much with it. Or you can modify
either of these bases in other ways and get lesser degrees of antagonism
with lesser subjective effects. Pentazocine is such a compound. It is,
at the same time, an agonist; that is, a morphine-like substance which
produces the morphine-like relief from pam and so on, as well as
being a mild antagonist. So that it can prevent the development of
morphine-like dependence or precipitate withdrawal phenomena if
given to a person dependent on morphine.

Mr. Perito. I assume the same would be true with cyclazocine and
naloxone.

Dr. Eddy. Cyclazocine is a modification of one of the synthetics.
Naloxone, on the other hand, is derived by modification of a morphine
derivative. Therefore, theoretically, we would require the availability
of opium in order to produce naloxone. Actually there is another
variety of poppy which produces one of the opium alkaloids in its
natural life history without producing morphine, and work is under-
way to develop this particular variety of poppy to get the starting
material to make naloxone without having, at the same time, an over-
supply of morphine.

Even though naloxone is morphine based, if I may put it that way,
it is theoretically possible to come to it without having to go through
morphine production.

Chairman Pepper. Doctor, if we could eliminate the legitimate need
for the growing of the opium poppy, and, if, as you suggested, we could
provide a comparable income to the grower of the opium poppy by
substituting some other crop that would not have these injurious
effects, do you think that would be in the public interest of this Nation
and the nations of the world ?

Dr. Eddy. Very definitely so. If you reduce the overall production
you must increase the trend toward the use of the substitutes.

If I might refer to the question that was asked of Dr. Seevers with
respect to the international situation when we came so close to ban-
ning the synthetics some years ago, it was largely an economic ques-
tion. The opium producing countries were afraid of the loss of their
income, of course, and they put forth the claim, or made the assertion,
that if we permitted the synthetics, we would develop a greater prob-
lem than we had in controlling opium, since we would develop the
opportunity for illicit production of the synthetics. Well, that prob-
lem has not developed and the manufacturing countries argued that
thev did not expect that it would develop.

Chemistry is not all that simple. If we were to cut off the supply
of opium completely we might be faced with some prol)lems along
those lines, because we know now that there are illicit manufacturers
of barbiturates and amphetamines in addition to the licit manufac-
ture. So we can't eliminate completely the possibility of illicit manu-
facture of synthetics if we turn to the synthetics in place of natural
alkaloids.

Chairman Pepper. Doctor, from your knowledge of the general field
and of the sums available for carrying on the very commendable re-
search in finding a synthetic substitute for morphine and codeine, and
also for the finding of an antagonistic drug to heroin, are the funds
presently available adequate to carry on the research programs that
vou think are desirable ?

Dr. Eddy. No.

Chairman Pepper. Therefore, Avoiild you think additional Federal
fluids would be in the public interest for these research programs ?

Dr. Eddy. Yes.

Chairman Pepper. Mr. Mann ?

Mr. Mann. Thank you.

Pursuing this economic problem just one step further, would there
be any allegation on the part of the opium-producing countries at this
point, or any justifiable allegation that the United States would have
any monopoly on the production of the synthetic drugs, or that the
cost of producing these synthetic drugs on a legitimate basis would
make the outlawing of opium economically bad for all other countries ?

Dr. Eddy. I don't think so, because the know-how is present in
other countries besides the United States. We do have a group of
manufacturing countries on the one hand and presently a group of
producing countries, if you want to call them that, the opium pro-
ducers, on the other hand. But my suggestion was that we put our
effort into giving the opium producers and producing countries, eco-
nomic and technical assistance so they can live without opium. We
can't expect to do this at their cost solely. We have got to do some-
thing about getting them to grow alternative crops. But once you have
done that I don't see that they have any allegation that we are taking
the bread out of their mouth.

Mr. Mann. Nothing further.

Chairman Pepper. Mr. Wiggins ?

My. Wiggins. Doctor, do you generally concur in the observations
made by Dr. Seevers that if the Congress were inclined to prohibit the
importation of morphine that such a statute should have immediate
effect? i- ■ }\ >''

Dr. Eddy. Well, I don't know — I am not sure that I know what
you mean by immediate. As of now, no. You couldn't do it quite that
quickly.

There is reluctance on the part of the physicians to use the syn-
thetics, justifiably so. They have been fooled more than once. Heroin
was introduced as a nonaddicting substance 75 years ago. It was
promptly proved to be — that was promptly proved to be — erroneous.
Demerol was introduced 30 years ago as a nonaddicting substance, even
though at the time that it went on the market we had evidence that it
was as dependence-producing as morphine itself. The producer dis-
agreed and claimed for a number of years, 6 or 8 years, that we were
wrong, that it did not produce morphine-like dependence. Later, they
did admit that we were right, that it did produce physical dependence,
and the}' have changed their advertising. It is now under narcotic
control — they advertise it now as a morphine-like substance.

Mr. Wiggins. Doctor, we both understand that if Congress were to
await a medical concensus that we would not act at all, just because the
doctors are, as has previously been testified to, an independent lot.
Nothwithstanding that, if Congress should make a determination that
it is in the public interest to prohibit the importation of morphine do
you know of any reason why that statute should not be made operative
as of its effective date, or would it be in the public interest to delay it
a month, 6 months, a year, 2 years, something on that order ?

Dr. Eddy. Well, physicians, usually physicians are not all that
familiar with new products. I think there should be some reasonable
delay in order to familiarize them with the substitutes. As I said
earlier, we banned heroin from the medical practice without too much
resistance, partly because we kept morphine, which in many instances
was advantafjeous over heroin and heroin was not all that popular in
the United States. When the attempt was made to ban heroin in Great
Britain there was a tremendous furor and the Home Office eventually
withdrew the ban and heroin is still permissible in Great Britain.

If we were to attempt to ban, by congressional action, the use of
morphine in clinical medicine I think there would very justifiably be
a fjood deal of resistance on the part of physicians. The natural opiates
are what they are accustomed to and you would have to give them an
opDortunity to become accustomed to things to be used alternatively.

Mr. WkvOtxs. I have difficulty in reconciling your statement that
medical resistance would be iustified in view of your earlier statement,
there are adequate substitutes for morphine now existing.

Dr. Eddy. Well, those substitutes are there, but not all of the physi-
cians in the country are aware of them and familiar with their use.
They would say: "Well, what am I going to do for John Jones for
whom I must have morphine in order to get him through this opera-
tion or to handle his broken leg or something else. I don't know any-
thing about this compound. I have never heard of it." You have got to
give him an opportunity to familiarize himself, carry on some sort of
campaign to get them to accept the alternative.

I was very active, took a very great interest in the introduction of
pentazocine. It was quite slow m coming on the market for reasons I
don't need to go into. I was particularly interested because it appeared
to be completely free of physical dependence factors, and it is reason-
ably so. We did not expect any abuse of it at all. There has been a
very small amount of abuse because a few people who have abused
other drugs have found the reactions of it pleasant to them and have
gone on to use excessive amounts, but the number is very small. It
does have antagonistic properties if given to a person already depend-
ent on morphine. It was likely the withdrawal phenomena would be
precipitated and would probably make him sick and probably very
angry with his doctor if the doctor w^as not aware of what was going
on. But the reaction to it has been exceedingly good. It is an agonist-
antagonist and physicians are accepting it, and I think we can get
them to accept it and other compounds of this sort to a sufficient ex-
tent so that medical practice would not suffer for lack of the opiates.
But this takes a little time.

Mr. Wtootns. I would like to ask two additional questions. Doctor.
How would you describe the ease of manufacturing the existing sub-
stitutes for morphine? That question is really aimed at whether or not
we can expect a lot of backyard or backroom clandestine laboratories
turninir out the substitutes if the United States were to prohibit the
use of morphine.

Dr. Eddy. Well, none of the synthetics are all that easy to produce.
It would require a very skilled, very well-equipped technical chemical
laboratory to produce them. It isn't anything like the ease with which
heroin is obtained from morphine. You can cook up hei-oin in your

kitchen from morpliine if you have a morphine supply. You can ex-
tract morphine from opium without very much difficulty.

Mr. Wiggins. Is it as easy as manufacturing LSD or more difficult?

Dr. Eddy. Well, given a supply of lysergic acid for the production
of LSD, the development of the synthetics in place of the natural opi-
ates would be much more difficult.

Mr. Wiggins. What would be the price for synthetics versus price of
morphine?

Dr. Eddy. Presently the price to the patient is practically the same
per dose for all the compounds we have been considering. We have al-
ready looked into that.

Mr. Wiggins. Thank you, Doctor.

Chairman Pepper. Mr. Steiger ?

Mr. Steiger. I have no questions.

Chaii-man Pepper. Mr. Winn ?

Mr. Winn. Thank you, Mr. Chairman.

Doctor, you have a statement here which says you believe drug de-
toxification has no effect on a person's craving for drugs. You spoke to
that a minute ago, and this same statement says that is what you re-
ferred to as the lesson of Lexington. Could you speak to that a little
bit more?

Dr. Eddy. Well, perhaps I can answer your question this way : So
far as we know, putting a patient through cold turkey, which means
withdrawing from opiate without any treatment at all, does not deter
him from relapse, relapse to the use of opiate once he is free of the
treatment as against treating him as humanely as possible. So there is
no point — there is no justification — for cold turkey treatment of a
drug-dependent person.

]\Ir. Winn. What you are saying, which you referred to a little while
ago, is that there would be no difference in the psychic craving ?

Dr. Eddy. That is right.

Mr. Winn. And not a physiological craving ?

Dr. Eddy. We can handle the physical dependence side of it without
difficulty, because we know how to take the person through withdrawal
so he does not suffer, to all intents and purposes, take him through
withdrawal with reasonable comfort.

But that doesn't necessarily affect his remembrance of the effects
that he got from the heroin he took or the oj^iate that he took previ-
ously or his desire to reexperience those effects. That is psychic
dependence.

Mr. Winn. Are you doing anything, or is anything being clone, to
offset this psychic dependency.

Dr. Eddy. Yes; of course. Any treatment program should include
psychotherapy to try to help the man to understand and meet his prob-
lems Avithout resort to drugs to convince him that the subjective effects
which he obtained were not essential to him, that life without drugs is
possible and reasonable and more productive, more rewarding.

Mr, Winn. Thank you very much, sir.

Thank you, Mr. Chairman.

Chairman Pepper. Doctor. I understand that in Britain, one way of
handling heroin addiction is to authorize the prescription of heroin
to addicts. Would you recommend that course in this country ?

Dr. Eddy. No.

Chairman Pepper. Now, would you care to comment about the use of
methadone as a drug in the treatment of heroin addiction?

Dr. Eddy. In the use of methadone you use, or you accustom, the
individual, you stabilize the individual on a dosage level which,
through the mechanism of cross-tolerance, prevents him from getting
anj' acute reaction to the methadone which he is taking or a dose of
heroin which he might take. Therefore, you stabilize him in a state
where he is in a stable mood so far as drug use is concerned and is of a
mind to turn his attention to other things rather than simply to his
previously drug-seeking behavior. Therefore, he no longer needs to go
out in the street and steal cars and televisions and so on to buy his
heroin. Ke has an opportunity to concern himself with getting a job
,and supporting his family.

Mr. Pepper. How do you think methadone should be furnished to
the addict?

Dr. Eddy. Through a team effort to help handle all of his problems,
not just simply to supply him with drugs, because you must have the
psychotherapy, the vocational assistance, the job help and housing
help, perhaps, and all this while he is stabilized on methadone. Other-
wise he has other reasons for trying to go back to other drugs, even
though he is not getting any satisfaction out of his heroin.

Chairman Pepper. In other words, a prescription of methadone by a
physician is not the answer to the problem alone ?

Dr. Eddy. Very definitely not. Theoretically, in a very rare instance,
it would be possible for a private physician with very close rapport
with his patient to put that patient on methadone and keep close con-
tact with him and treat him satisfactorily. But practically, writing pre-
scriptions for drug-dependent people for methadone, letting them go
to tlie drugstore and buy it without doing anything else for him, is
not the answer at all. You just give him the opportunity to use exces-
sive amounts of methadone or to sell some of it to somebody else, go to
another doctor and get some more. You have no control over the prop-
osition at all. You have not accomplished what you have set out to do.

Chairman Pepper. Doctor, one other question.

What is your opinion as to the medical need for amphetamines^

Dr. Eddy. The legitimate need is very small indeed.

Mr. Wiggins. Doctor, what is the difference between methadone
maintenance or stabilization and heroin maintenance or stabilization,
assuming the heroin was made available at no cost or minimum cost
to the patient ?

Dr. Eddy. Theoretically, none when you supply the heroin. If you
are going to be successful you have got to supply him \yith enough
heroin to maintain him in a reasonably stable state. Practically, there
are differences because at the present time they are still^ sujiplying
heroin in England to be taken by injection, which maintains the
ritual of heroin abuse which the individual has been subject to pre-
viously. In the methadone maintenance program the drug is given by
mouth and therefore you upset the ritual, which goes along with his
dependence, and probably is a very significant factor in the mainte-
nance of dependence.

Put more than that, you can build up to a dose of methadone which
will maintain the individual in the stable state throughout the 24-

hour period. It is exceedingly difficult to do that with heroin because
heroin is so short acting and particularly ineffective by mouth. Meth-
adone is nearly as effective by mouth as it is by injection. Heroin is
much less effective by mouth. That is why they stick to the injection
route, and it would be exceedingly difficult to stabilize a person on
heroin given by mouth, almost impossible.

But theoretically in both instances you are simply maintaining the
individual's dependence by giving him another opiate.

Chairman Pepper. Any more questions ?

Mr. Steiger. Just one.

Dr. Eddy, in your work with Dr. Seevers in his primate laboratory
did you see any symptoms of the psychic dependence, or is there any
method of observing that ?

Dr. Eddy. There are programs going on in a number of laboratories
directed toward that very thing. As a matter of fact, we are very
hopeful that in the not too distant future we will have techniques for
measuring drug seeking behavior through offering the drugs to the
primates for self-administration. This is a very promising line of re-
search that is going on in Dr. Seevers' laboratories and other labora-
tories as well. It is a different approach from what he described where
we were attempting to assess the dependence liability of compounds
sent to him under code designation.

Mr. Steiger. Is there any investigation in which we are attempting
to support psychic independence by chemical means? Has that been
explored? Is it not conceivable? Is that a part of what you just
described ?

Dr. Eddy. I am not sure what you mean.

Mr. Steiger. In which we can reach the psychic dependence chemi-
cally or by

Dr. Eddy. Well, you do. In methadone maintenance or heroin main-
tenance you are administering the same type of drug upon which the
individual is dependent psychically and physically, so you satisfj'^ his
psychic as well as physical craving.

]Mr. Steiger. I understand that. Is there any attempt to find a chem-
ical which will allow the patient to overcome the psychic dependence
without the need for all of the social requirements that we now have ?
Is that not achievable, in your opinion ?

Dr. Eddy. Perhaps. Dr. Keats once said when he first began study-
ing the antagonists — Dr. Keats is a very skilled person in clinical
medicine and very much involved with some of the new compounds —
he once said that perhaps the solution to our problem was to develop
a compound which made the individual uncomfortable and yet re-
lieved his pain. If he could be persuaded to take cyclazocine as an
analgesic in the ordinary clinical situation he would probably at some
times, at least, be pretty uncomfortable. He wouldn't like it very
much. But if he got sufficient relief of pain he might be able to tolerate
the unpleasantness until tolerance to it developed. The pharmaceutical
houses have not been willing to take that gamble.

There is a related compound, one of the synthetic groups, actually
as potent as cyclazocine. I discussed with the manufacturer the possi-
bility of pursuing it as a drug for clinical medicine, hopefully that
there would be enough difference between the dose level for the dis-
agreeable side effects and for the pain-relieving effect so that we could

get away with it as Dr. Keats suggested. The company did make a
brief trial but the results were even worse than with cyclazocine and
they would have nothing further to do with it.

But something along those lines may be possible. Pentazocine in
some circumstances, and in some individuals, has had disagreeable
side effects though to a lesser degree then cyclazocine, but it is being-
accepted by physicians and patients at the present time. So in a sense
we have accomplished w4iat we are striving for.

Mr. Steigek. Thank you, sir.

Chairman Pepper. ]\Ir. Keating ?

jMr. Keating. No questions.

Chairman Pepper. Mr. Perito, do you have anything to put in the
record or any other questions ?

Mr. Perito. Yes, Mr. Chairman, I would like to offer for the recoi-d
the prepared statement and curriculum vitae of Dr. Eddy.

Chairman Pepper. Without objection they will be received.

Dr. Eddy, we wish to than you very much for coming here and giv-
ing us from your vast knowledge and experience the encouraging testi-
mony you have given us this morning.

Thank you very much.

Dr. Eddy. It has been a privilege and a pleasure to talk with you.

(The material referred to follows :

[Exhibit No. 4(a)]

Prepared Statement of Dr. Nathan B. Eddy, Chairman, Committee on Prob-
lems OF Drug Dependence, Division of Medicax Sciences, National Academy
OF Sciences-National Research Council

The Select Committee on Crime has seen the resolutions of the Committee on
Drug Addiction and Narcotics, Division of Medical Sciences, National Research
Council, the earliest of which has been quoted by Dr. Seevers today. These resolu-
tions maintain that medical practice, and the patient, would suffer no loss if the
natural alkaloids of opium, and substances derived from them, were not available.
All medical indications for morphine and/or codeine, as well as for substances
semisynthetically derived from them, can be met by substances of wholly synthetic
origin. Adequate substitution is possible. Is it practical or advantageous? Many
considerations must enter into the answer to this question. Dr. Seevers and Dr.
Brill have, or will, discuss some of them. Obviou^^ly the advantages and disad-
vantages of potential substitutes are important, so I offer for the record brief
summaries of some replacements already on the market. The presentation is in
approximate chronological order.

Pethidine (meperidine, Demerol®) was the first wholly synthetic morphine-
like analgesic, the characteristics of which were discovered only incidentally.
Close scrutiny, however, revealed that its structure corresponded ro an internal
part of the morphine molecule, hence, presumably, its morphine-like properties.
As with heroin 40 years earlier, pethidine was introduced as not dependence-
producing, a claim which undoubtedly was of great importance in building the
drug's popularity and is in vogue among many physicians even today. Fortunately
we liavc not again been so far off the mark. The optimal analgesic dose of pethi-
dine, effective against many types of pain, is 100 nig. approximately equivalent
to 10 mg. of morphine when each is given intramusculary. Pethidine is available
for oral administration, usually in combination with aspirin, but its effective-
ness by this route is not as great as the small dose in the cominerical preparation
seems to indicate. The use of pethidine is accompanied by the same sort of side
effects as are associated with the use of morpliine witli only minor quantitative
differences. Sleepiness and constipation may be less frequent, a feeling of well-
being more frequent. It produces respiratory depression, relative to its analgesic
action, at least as great as that following morphine, and is probably more likely
to cause a fall in blood pressure. Pethidine has been used widely in obstetrics

and may facilitate dilation of the cervix, but it may also decrease uterine con-
tractions and it does not necessarily shorten labor. Pethidine has a significant
effect on the infant, increasing the frequency of delay in first breath and cry.
This depression is less than when the barbiturates are used and i)rol)abIy less
than with administration of morphine, but it is definite and should not be re-
garded lightly. From the very first tests for determination of the possibility,
pethidine has been shown to be dependence-producing and many cases of de-
pendence on it, of morphine type, have been reported, especially among medical
and ancillary personnel. The euphorigenic and dependence-producing dose of
pethidine is close to its optimal analgesic dose, so that its dependence liability
relative to its analgesic action is much like that of morphine.

Methadmie (Dolophine®), though apparently dissimilar to morphine in struc-
ture, can produce qualitatively essentially all of moi-phine's actions and in many
respects is quantitatively equivalent. It is more effective than morphine when
taken by mouth and its euphorigenic action persists longer vphether the oral or
parenteral route is employed. Tolerance, cross-tolerance, and dependence develop
as with morphine and the side effects of methadone and morphine are similar.
The withdrawal syndrome after chronic administration of methadone develops
more slowly, is less intense, and is longer in duration than the morphine absti-
nence syndrome. Methadone is a good enough suppressant. There should be no
difficulty in using methadone wherever morphine is indicated but its abuse
liability is as great as with morphine.

Normethadonc is closely similar to methadone in structure and action, but
has been used only in a mixture as a cough suppressant. The addition of the
other active constituent in the marketed mixture, Ticarda : namely Suprifen,
does not reduce abuse liability and may indeed increase it because of its am-
phetamine-like stimulant subjective effects. Cases of dependence in clinical prac-
tice have been described. While at least as effective as codeine, according to the
usual therapeutic doses, for cough relief, the abuse liability or normethadone
is greater.

Levorphanol (Dromoran®) is a result of attempts to synthesize morphine in
the laboratory and has the structure minus three chemical features. It is
morphine-like in its action in all respects and dosewise is several times more
powerful. It is particularly effective when taken by mouth. Again it could be
used for all morphine indications, but there would be no reduction in dependence
liability.

Dea:ftrometh orphan (Romilan®) is structurally related to codeine as levorpha-
nol is related to morphine, but it is qualitatively different in some respects. It
does not have pain-relieving potency, but is as effective as codeine for the relief
of cough. It will not support an established dependence of morphine-type but
the sul)jective effects of large doses, mainly psychotomimetic rather than mor-
phine-like, are appreciated by some subjects and a few cases of abuse have
been encountered. Preparations of dextromethorphan are available over the
counter.

Phenazocine (Prinadol®, Narphen®) is a result of further simplification of the
morphine molecvile, or of less-advanced synthesis toward the morphine molecule.
It is a basic structure present in morphine and levorphanol and represents fur-
ther deletion of certain chemical features. It is qualitatively similar to morphine
in its action but shows some quantitative differences. Analgesic potency is pres-
ent in phenazocine about on a par with that of levorphanol, that is, several times
greater than with morphine. Side effects are similar with all three drugs. De-
pendence capacity is reduced definitely, as measured by animal experiments,
but little as judged by quantitative comparisons in man. Phenazocine is effective
orally, often nearly as effective as after parenteral injection, and therein may lie
its greatest u.sefulness. Oral phenazocine has been well received in England' and
other countries : it has not been marketed for oral use in the United States.

Propoxyphene (Darvon®) is structurally related to methadone and has en-
joyed wide popularity as a mild oral analgesic, especially ia combination with
APC (aspirin, phenacetin, and caffeine). An intensive review of manv studies,
comparing the drug w^ith codeine, or with aspirin, or APC, concluded that even
the mixture with APC hardly equaled the oral effectiveness of codeine and
certainly did not surpass it. Propoxyphine can produce morphine-like subjective
effects, supports an established morphine dependence poorly, but has measurable
dependence-producing capacity. Cases of abuse have been reported. However,
after 5 years of marketing experience, the abuse liability of propoxyphene as a

60-296— 71— pt. 1 i

public health hazard was judged not to warrant narcotics control, nationally or
internationally.

Caramiphen (Parpanit®) is not related chemically to any of the compounds
which have been described. It was introduced as a relaxant and later shown
to have cough-suppressant action, but there have been few controlled studies
comparing it with codeine. Few side effects have been reported and no case of
dependence or abuse.

Benzonatate (Tessalon®) is also unrelated to the morphine structure, but is
claimed to have a suppressant effect on cough reflexes both at the site of irrita-
tion peripherally and at the responding center in the nervous .system. Again
there have been few carefully controlled .studies. The recommended therapeutic
dose is at least three times larger than for codeine and tolerance to the cough-
relieving action may occur.

Pentazocine (Talwin®) is a member of the benzomorphan series of which
phenazocine was the first marketed example, and illustrates our most promising
leads for opiate substitution. These constitute two underlying basic principles :
(1) Animal experiments have shown consistently greater dissociation of pain
relief and dependence capacity among the benzomorphans, which represent only
partial synthesis toward morphine, than in any other chemical group. This
ti'end has been partially confirmed in studies in man; (2) Whether the basic
structure is morphine, morphinan, or benzomorphan, certain modifications have
led to the appearance of specific antagonistic properties simultaneously with
the retention of some morphine-like action. Compounds displaying such a com-
bination of effects are classified as agonist-antagonists and pentazocine is in
this group. It relieves pain satisfactorily, given orally or parenteral] y at a dose
about four times greater than for morphine. Side effects with therapeutic doses
are morphine-like. Pentazocine is also a weak morphine antagonist and will not
support an established morphine dependence. Chronic administration of pentazo-
cine causes the appearance of some dependence and a mild abstinence syndrome
when the drug is abruptly withdrawn. Both the dependence and the abstinence
syndrome are partly like, partly unlike, these phenomena with morphine. There
is less drug-seeking behavior. The clinical effectiveness of pentazocine is being
well received by physicians and patients. A few cases of abuse have been re-
ported, very few in relation to the total doses prescribed. The drug has not
been subjected to narcotics control.

The foregoing descriptions confirm, I think, that we can do without morphine
and codeine but the book on opiate substitution is not closed. Not only is the
agonist-antagonist group undergoing and worthy of much further study, but
there are other compounds of diverse structure in development, following fur-
ther dissociation of dependence capacity and therapeutic action.

[Exhibit No. 4(b)]

Curriculum Vitae of Dr. Nathan Browne Eddy, Chairman, Committee of
Problems of Drug Dependence, Division of Medical Sciences, National
Academy of Sciences-National Research Council

Date and place of birth : Glens Falls, N.Y, August 4, 1890.

Family: Wilhelmina Marie Aherns (wife); Charles Ernest Edjdy (son), de-
ceased.
Education and degrees : 1911 — Cornell University Medical School — M.D. : 1963 —

University of Michigan — D. Sc. (honorary).
Special training or experience :

1911-16 — Practice of medicine. New York City.

1916-20 — Instructor of physiology, McGill University ; teaching and research.

1926-28 — Assistant professor, physiology and pharmacology, T^niversity

of Alberta — teaching and research.
1928-30 — Associate professor of pharmacology, University of Alberta, teach-
ing and Research.

1927 (May-September) Visiting investigator. Department of Pharmacology,
Cornell University Medical School.

1928 (May-September) Visiting investigator and lecturer. Department of
Physiology, University of Michigan Medical School.

1929 (May-September.) Visiting investigator and lecturer, Department of
Physiology, University of Michigan Medical School.

1930-39 — Research professor in pharmacology, University of Michigan —
rGSGcircli.

1980-39 — Consultant Biologist in Alkaloids, U.S. Public Health Service.

1939-49 — Princii)al Pharmacologist, National Institutes of Health.

1949-60 — Medical Officer, General, National Institutes of Health.

1951-60 — Chief, Section on Analgesics, Laboratory of Chemistry. National
Institute of Arthritis and Metabolic Diseases, National Institutes of Health
—retired August 31, 1960.

1960 — Consultant on Narcotics, National Institutes of Health.

1961-67 — Professional Associate, designated Executive Secretary, Com-
mittee on Drug Addiction and narcotics, Medical Division, National Re-
search council.

1968 Consultant, Bureau of Narcotics and Dangerous Drugs.

1969 Consultant New York State Narcotic Addiction Control Commission.

1970 Consultant Le Dain Commission on Nonmedical Use of Drugs.

Membership in professional organizations :

Society of Pharmacology and Experimental Therapeutics.

American Association for the Advancement of Science.

Society for Experimental Biologyand Medicine.

Sigma Xi.

Editorial board, Excerpta Medica ; editorial advisory board "Voice of
America".

Society for the study of addiction to alcohol and other drugs.

Washington Academy of Sciences.

American College of Clinical Pharmacology and Chemotherapy.

Institute for the Study of Addiction.

College of Neuropsychopharmacology.

Eastern Psychiatric Research Association.
Committee appointments, etc. :

Committee on Drug Addiction and Narcotics (Problems of Drug Depend-
ence), National Research Council, Secretary 1947-61; chairman 1970.

U.S. Public Health Service Drug Addiction Committee (resigned).

U.S. Public Health Service Post Office Advisory Committee, (resigned).

Bureau of Narcotics Advisory Committee on Oral Prescription bill. Ad hoc.

Advisory Committee under Narcotics Manufacturing Act of 1960.
Chairman, 1961.

Expert Panel on Addiction-Producing Drugs, World Health Organization ;
member of each expert committee chosen from this panel ; chairman of
Committee on first, second, eighth, ninth, 12th, 13th, and 16th sessions.

Technical Adviser, U.S. Delegation to United Nations Commission on Nar-
cotic Drugs. 1947, 1948, 1957, and 1958.

Technical Committee, United Nations Plenipotentiary Conference on Single
Convention on Narcotics Control, 1961.

Special Consultant to Addiction-Producing Drugs Section, World Health
Organization, 1954, 1955, 1956, 1959, and 1961.

Consultant to Army Chemical Center.

American Social Health Association Advisory Committee on Narcotic Addic-
tion.

Delegate and Panelist, Wliite House Conference on Narcotic and Drug Abuse,
September 27-28, 1962.

Alternate delegate for ASHA National Coordinating Council on Drug
Abuse Information and Education.
Honors and Awards :

Corecipient, First Annual Scientific Award, American Pharmaceutical
Manufacturers Association, 1939.

Guest speaker, Royal Canadian Institute, Toronto Ontario, Canada, March
28, 1953.

Lister Memorial Lecture, October 1, 1959, Edinburgh, Scotland.

Public Health Service Superior Performance Award for Sustained Outstand-
ing Service, August 31, 1960.

Delegate and gue.st speaker, Los Angeles Conference on Narcotic and Drug
Abuse, April 27-28, 1963.

Guest speaker, Hawaiian Pharmaceutical Association, Honolulu, May 4, 1963.

D. Sc (honorary) University of Michigan, 1963.

Dent Lecturer, Society for the Study of Addiction, London, 1967.

WHO Medal for Distinguished Service, 1969.

Snow Medal of American Social Health Association, 1969.

Gold Medal of Eastern Psychiatric Research Association, 1970.

Bibliography

Med. Assn., 60 : 1296, 1913.
(3> Ardrey W. Downs and Nathan B. Eddy. "The influence of secretin on
number of erythrocytes in the circulating blood." Am. J. Physiol., ^3 :
415-428, 1917.
"Secretin : II. Its influence on the number of white corpuscles in

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Nathan B. Eddy. "A case of arrested development of pancreas and intes-
tine." Anatomical Record, 6 : 319-323, 1912.

"Recovery in brain syphilis after the use of salavarsan." J. Am.

circulating blood." Am. J. Physiol., 45 : 294-801. 1918.

"Secretin : III. Its mode of action in producing an increase in the

number of corpuscles in the circulating blood." Am. J. Physiol.. 46
209-221. 1918.

'Secretin : IV. The number of red and white corpuscles in the cir-

culating blood during digestion." Am. J. Physiol., -)? : 399-403, 1918.

"Secretin and the change in the corpuscle content of the blood dur-

ing digestion." J. Fla. Med. Assn., 5 : 101-106, 1916.

Nathan B. Eddy. The role of the thymus gland in exophthalmic goitre."
Canadian Med. Assn. J., 9 : 203-213, 1919.

Audrey W. Downs and Nathan B. Eddy. "The influence of internal secre-
tions on the formation of bile." Am. J. Physiol., 48 : 192-198, 1919.

"The influence of spenic extract on the number of corpu.s'cles in

the circulating blood." Am. J. Physiol., 51 : 279-288, 1920.

"Effect of subcutaneous injections of thymus substance in young

rabbits." Endocriu., 4 : 420-428, 1920.

"Extensibility of muscle : The effect of stretching upon the develop-

ment of fatigue in a muscle." Am. J. Physiol., 56 : 182-187, 1921.

"Extensibility of muscle: The production of carbon dioxide by a

muscle when it is made to support a weight." Am. J. Physiol.. 56 : 188-

195, 1921.
Nathan B. Eddy. "The internal secretion of the spleen." Endocrinologv.

5 : 461-475, 1921.
"A simple device for the demonstration of heart block in the

student laboratory." J. Lab. and Clin. Med., 6 : 635-638, 1921.
Ardrey W. Downs and Nathan B. Eddy. "Secretin. V. Its effect in anae-
mia with a note on the supposed similarity between secretin and vitamin

B." Am. J. Physiol., 58 : 296-300, 1921.
"Further observations on the effect of the subcutaneous injection

of spenic extract." Am. J. Physiol., 62 : 242-247, 1922.

"Some unusual appearances of nucleated erythrocytes in the cir-

culation following repeated injection of splenic extract." Am. J. Phvsiol..
63 : 479-483, 1923.

"Secretin and a suggestion as to its therapeutic value." Endocrin-

ology, 7 : 713-719, 1923.
Nathan B. Eddy. "The action of preparations of the endocrine glands

upon the work done by skeletal muscle." Am. J. Phvsiol., 69 : 430-440,

1924.
Ardrey W. Downs and Nathan B. Eddy. "Secretin : VI. Its influence on

the antibodies of the blood." Agglutinin. Am. J. Physiol., 77 : 40-43, 1924.
Ardrey W. Downs, Nathan B. Eddy, and Robert M. Shaw. "Secretin :

VII. Its inflence on the antibodies of the blood." Complement. Am. J.

Physiol., 71 : 44-45, 1924.
"Secretin: VIII. Its influence on antibodies of the blood: Haemolv-

tic amboceptor." Am. J. Physiol., 71 : 46-48. 1924.
Nathan B. Eddy and Ardrey' W. Downs. "Blood regeneration." Canadian

Med. Assn. J., 16 : 391-396, 1926.
"Secretin : IX. Its relation to the activity of skeletal muscle." Am.

J. Physiol., 7.^ : 489-490, 1925.
Nathan B. Eddy. Studies on hypnotics of the barbituric acid series."

J. Pharmacol, and Exper. Therap.. 33 : 43-68. 1928.
Nathan B. Eddy and Ardrey W. Downs. "Tolerance and cross-tolerance

in the human subject to the diuretic effect of carreiue. theobromine.

and theophylline." J. Pharmacol. & Exper. Therap., 33: 167-174. T92S.

(28) Nathan B. Eddy and Robert A. Hatcher. "The seat of the emetic action

of the digitalis bodies." J. Pharmacol, and Exper. therap., 33 : 295-300,
1928.

(29) Ardrey W. Downs and Nathan B. Eddy. "Morphine tolerance: I. The
acquirement, existence and loss of tolerance in dogs." J. Lab. and Clin.

Med., 13 : 739-745. 1928.

(30) "Morphine tolerance: II. The susceptability of morphine tolerant

dogs to codeine, heroin and scopolamine." J. Lab and Clin. Med., 13 :
745-749, 1928.

(31) Ardrey W. Downs, Nathan B. Eddy, and John P. Quigley. "Morphine

tolerance : III. The effect of cocaine upon dogs before, during and after
habituation to morphine." J. Lab. and Clin. Med.. 13 : 839-842, 1928.

(32) Nathan B. Eddy. "The regulation of respiration: XXVII. Tlie effect upon

salivary secretion of varying the carbon dioxide and oxygen content of
of the inspired air." Am. J. Physiol., 88: 534-545, 1929.

(33) "The effect of the repeated administration or diethyl barbituric

acid and of cyclohexenylethyl barbituric acid." J. Pharmacol. & Exper.
Therap., 37: 261-271, 1929.

(34) "The excretion of diethyl barbituric acid during its continued ad-
ministration." J. Pharmacol. & Exper. Therap. 37; 273-282, 1929.

(35) Ardrey W. Downs and Nathan B. Eddy. "The influence of Tyramine on

the number of red corpuscles in the circulating blood." Proc. Soc. Exper.
Biol. & Med., 27: 405-407, 1930.

(36) Nathan B. Eddy. "Antagonism between methylene blue and sodium cya-

nide." J. Pharmacol. & Exper. Therap., 39: 271, 1930. (Proc.)

(37) "Regulation of respiration. The effect upon salivary secretion of

the intravenous administration of sodium bicarbonate, sodium carbon-
ate, sodium hydroxide, sodium chloride, and sodium sulphate." Quart.
J. Exper. Physiol., 20: 313-320, 1930 (8 plates).

(38) "Regulation of respiration. The effect upon salivary secretion of

the intravenous administration of lactic acid, sodium lactate, and hydro-
chloric acid." Quart. J. Exper. Physiol., 20: 321-326. 1930 (5 plates).

(39) —"Regulation of respiration. The effect upon salivary secretion of

the intravenous administration of ammonium chloride and ammonium
carbonate." Quart. J. Exper. Physiol., 20: 327-332, 1930 (5 plates).

(40) "Regulation of respiration. The effect upon salivary secretion of

an increased oxygen content of the inspired air and of forced venti-
lation." J. Pharmacol. & Exper. Therap., 4I: 42.3-433, 1931.

(41) "Regulation of respiration. The effect upon salivary secretion of

the intravenous administration of sodium sulphide, sodium cyanide and
methylene blue." J. Pharmacol. & Exper. Therap.. 4I: 435-447, 1931.

(42) "Regulation of respiration. The antagonism between methylene

blue an dsodium cyanide." J. Pharmacol. & Exper. Therap., 4i-' 449-464,
1931.

(43) "The action of the codine isomers and some of their derivatives."

J. Pharmacol. & Exper. Therap., 45: 236, 1932. (Proc.)

(44) "A comparison of phenanthrene and some 2-, 3-, and 9-monosubsti-

tution products." J. Pharmacol. & Exper. Therap., 45: 257, 1932. (Proc.)

(45) Nathan B. Eddy and A. Kenneth Simon. "The measurement of the de-

pressant action of the codeine isomers and related substances by the
use of mazetrained rats." J. Pharmacol. & Exper. Therap., 45: — , 1932.
(Proc.)

(46) Hugo M. Kreugar and Nathan B. Eddy. "A study of the effects of codeine

and isomers on the movements of the small intestine." J. Pharmacol. &
Exper. Therap., 45: 266, 1932. (Proc.)

(47) Nathan B. Eddy. "Studies of morphine, codeine, and their derivatives:

I. General Methods." J. Pharmacol. & Exper. Therap., 45: 339-359, 1932.

(48) "Studies of morphine, codeine, and their derivatives: II. Isomers

of codine." J. Pharmacol. & Exper. Therap., 45: 361-381, 1932.

(49) Ardrey W. Downs and Nathan B. Eddy. "Influence of barbital upon

cocaine poisoning in the rat." J. Pharmacol. & Exper. Therap., 45: 383-
387, 1932.

(50) "Effect of repeated doses of cocaine on the dog." J. Pharmacol. &

Exper. Therap., 46: 195-198, 1932.

(51) "Effect of repeated doses of cocaine on the rat." J Pharmacol. &

Exper. Therap., 46: 299-200, 1932.

(52) Nathan B. Eddy. "Dilaudid." J. Am. Med. Assn., 100: 1031-1035, 1933.

(53) Gerald G. Woods and Nathan B. Eddy. "Some new alkamines of the

tetrahydronapthalene series." J. Pharmacol. & Exper. Therap., 48: 175-
181, 1933.

(54) Nathan B. Eddy. "Studies of phenanthrene derivatives : I. A comparison

of phenanthrene and some 2-, 3-, and 9-monosubstitution products." J.
Pharmacol. & Exper. Therap., 48: 183-198, 1933.

(55) "Studies of the relation of the hydroxyl groups of morphine to its?

pharmacological action." J. Pharmacol. & Exper. Therap., 48 : 271, 1983.
(Proc.)

(56) "Studies of morphine, codeine, and their derivatives : III. Morphine

methochloride and codeine methocloride." J. Pharmacol. & Exper.
Therap,. 49: 319-327, 1933.

(57) "Studies of morphine, codeine, and their derivatives: IV. Hydro-

genated codine isomers." J. Pharmacol. & Exper. Therap., 51: 35-4:4,
1934.

(58) "Studies of phenanthrene derivatives: II. Monosubstitution prod-
ucts, first variations. The effect of muzzling the hydroxyl group of 2- or
3-hydroxyphenanthrene." J. Pharmacol. & Exper. Therap., 51: 75-84,
1934.

(59) Charles W. Edmunds and Nathan B. Eddy. "Some studies on the drug

addiction problem." Michigan Alumnus Quarterly Review, 4^: 250-257,
1934.

(60) Charles W. Edmunds, Nathan B. Eddy, and Lyndon P. Small. "Studies

on morphine addition problem." J. Am. Med. Assn.. 103: 1417, 1934.

(61) Nathan B. Eddy. "Studies of phenanthrene derivatives: III. Di-subst.
'f>= products." J. Pharmacol. & Exper. Therap., 52 : 275-289, 1934.

(62) Nathan B. Eddy and John G. Reid. "Studies of morphine, codeine, and

their derivatives: VII, Dihydromorpliine (paramorphan), dihydro-
morphinene, (Dilaudid), and dihydrocodeinone (Dicodide)." J.
Pharmacol. & Exper. 52 : 468-493, 1934.

(63) Nathan B. Eddy and Homer A. Howes. "Studies of morphine, codeine,

and their derivatives : VIII. Monoacetyl- and diacetylmorphine and
their hydr. derivatives." J. Pharmacol. & Exper. Therap., 53: 430-439,
1935.

(64) Nathan B. Eddy. "Phenanthrene studies. The effect of different nitric-

taining side-chains." J. Pharmacol. & Exper. Therap., 54 : 149, 1935.

(65) A. Kenneth Simon and Nathan B. Eddy. "Studies of morphine, codeine,

and their derivatives : V. The use of maze-trained rats to study the effect
on central nervous system of morphine and related substances." Am. J.
^7 : 597-613, 1935.

(66) Nathan B. Eddy and Bertha Aheens. "Studies of morphine, codeine, and

their derivatives : VI. The measurement of the central effect of codeine,
hydrocodeine, and their isomers bv the use of maze-trained rats." Psy-
chol., ^7 : 614-623, 1935.

(67) Nathan B. Eddy. "Studies of morphine, codeine, and their derivatives:

Methyl ethers of the morphine and codeine series." J. Pharmacol. &
Therap., 55 : 127-135. 1935.

(68) Nathan B. Eddy and Homer A. Howes. "Studies of morphine, codeine,

and their derivatives : X. Desoxymorphine-C, desoxycodeine-C and their
hydro derivatives." J. Pharmacol. & Exper. Therap., 55 : 257-267, 1935.

(69) Natpian B. Eddy. "Studies of phenanthrene derivatives: V. Homologous

and aldehvdes and some of their derivatives." J. Pharmacol. & Exper.
Therap., 55 : 354-364, 1935.

(70) "Studies of phenanthrene derivatives : VI. Amino alee of the ethan-

olamine and propanolamine type." J. Pharmacol. & Exper. 55 : 419-429,
1935.

(71) "Studies of morphine, codeine, and their derivatives: The isomers

of morphine and dihydromorphine." J. Pharmacol. «& Exper. 56' : 429-431,
1936.

(72) "Studies of phenanthrene derivatives: 'SMI. A comparing analogous

phenanthrene and dibenzofurau derivatives." J. Pharmacol. Exper.
Therap., 58 : 159-170, 1936.

(73) ^"Drug Addiction. Pharmacological Studies." Hosp. New 34, 1936.

(74) Nathan B. Eduy and C. K. Himmelsbach. "Experiments on the tolerance-

and addiction potentialities of dihydrodesoxymorphiue-D ("Desomor-
phine")." Suppl. No. 118 to the U.S. Public Health Reports. 33 pp.. 1936.

(75) Nathan B. Eddy. "Analgesic and other effects of some carbazoles." J.

Pharmacol. & Exper. Therap., 60: 105, 1937 (Proc.)

(76) "The search for more effective morphine-like substitutes." Am. J.

Med. Sc, J97 : 464^79, 1939.

(77) Lyndon F. Small, Nathan B. Eddy, Erich Mosettig, and C. K. Himmels-

bach. "Studies on drug addiction. With special reference to chemical
structure of opium derivatives and allied synthetic substances and their
physiological action." Suppl. No. 138 to U.S. Public Health Reports, 143
pp., 1939.

(78) Nathan B. Eddy. "Studies of carbazole derivatives: I. Amino-carbazoles."

J. Pharmacol. & Exper. Therap., 65 : 294-307, 1939.
(79) "Studies of carbazole derivatives: II. Amino alcohols and deriva-
tives of tetrahydrocarbazole." J. Phai-macol. & Exper. Therap., 65 : 308-
317, 1939.

(80) "Studies of morphine, codeine, and their derivatives: XIV. The

variation with age in the toxic effects of morphine, codeine, and some
of their derivatives." J. Pharmacol. & Exper. Therap.. 66 : 182-201, 1939.

(81) Nathan B. Eddy and Margaret Sumwalt. "Studies of morphine, codiene,

and their derivatives : XV 2,4-Dinitrophenylmorphine." J. Pharmacol,
& Exper. Therap., 67 : 127-141, 1939.

(82) Nathan B. Eddy. "Pharmaceutical education and the public health." Am.

J. Pharmaceut. Ed., 181-186, 1942.

(83) Hugo Krueger, Nathan B. Eddy, and Margaret Sumw^alt. "The Pharma-

cology of the Opium Alkaloids." Suppl. No. 165 to the Public Health
Reports, 1448 CXL pp., 1943.

(84) Nathan B. Eddy. "4,4-Diphenyl-6-dimethylamino-heptanone-3 : A new syn-

thetic morphine-like analgesic." Soc. for Exper. Biol. & Med., Washing-
ton Section, April 1947.

(85) "Metopon hydrochloride." J. Am. Med. Assn., 134: 219-292, 1947.

(86) Harris Isbell, Abraham Wikler, Nathan B. Eddy, John L. Wilson, and

Clifford F. Moran. "Tolerance and addiction liability of 4,4-diphenyl-
6-dimethylamino-heptanone-3 (Methadone)." J. Am. Med. Assn., 135:
883-894, 1947.

(87) Nathan B. Eddy. "Metopon." J. Am. Pharmaceut. Assn., Pract. Pharmac.

Education, 8 : 430-433, 1947.

(88) "A new morphine-like analgesic." J. Am. Pharm. Assn., Pract.

Pharm. Ed.. 8 : 536-540, 1947.

(89) "Analgesic drugs in cancer therapy." Fourth International Cancer

Research Congress, St. Louis, Sept. 5, 1947. Acta L'Union luteruat.
Cong. Cancer, 6 : 1379-1385, 1950.

(90) "Metopon." Am. Soc. Anesthesiologists — Symposium on New Drugs,

New York, Dec. 5, 1947.

(91) "Progress in Drug Therapy of Pain." Am. Pharmaceut. Monuf.

Assn., Annual Award Meeting, New York, Dec. 16, 1947. Am. Prof.
Pharmacist, 14 : 252-253, 1948.

(92) "Metopon hydrochloride." Canad. Med. Assn. J. January 1947.

(93) "Metopon hydrochloride (Methyldihydromorphinone hydrochlo-
ride)." Report to the Council on Pharmacy and Chemistry of the AMA
by the Committee on Drug Addiction and Narcotics of the National Re-
search Council. J. Am. Med. Assn., 137 : 365-367, 1948.

(94) "Newer analgesics in the control of pain in cancer patients." Post-
graduate symposium on Cancer, Medical College of Virginia, Rich-
mond, Va. Mar. 25, 1948. Unpublished.

(95) "Newer preparations for pain relief." Read Apr. 16, 1948. George

Washington University Medical School. Postgraduate course. Unpub-
lished.

(96) "Progress in drug therapy of pain." Adapted from No. 91. Read

at Staff Meeting of Arlington Hospital, Arlington, Va. May 6. 1948.
Unpublished.

(97) "Pharmacology of Metopon and other new analgesic opium deriva-
tives." New York Academy of Science. May 14-15, 1948. Ann. N.Y.
Acad. Science, 51 : 51-58, 1949.

(98) "The New Narcotics, Post-graduate Course in Internal Medicine

of tlie American College of Physicians, May 22, 1948." Am. Practitioner,
3 : 37^2, 1948.

(99) "Cooperation on Narcotics." Drug & Allied Indust., 5: 8-11, 1949.

(100) . "Metopon hydrochloride. An Experiment in Clinical evaluation."

U.S. Public Health Reports, 64 : 93-103, 1949.

(101) - — —"Progress in drug therapy of pain." Am. Professional Pharmacists,

14 : 2.52, 1948.

(102) "The relation of chemical structure to analgesic action." J. Am.

Pharmaceut. Assn., Sc. Ed., 39 : 24.5-251, 1950.

(103) Nathan B. Eddy, Caroline Fuhrmeister Touchberrt, and Jacob E.

LiEBERMAN. "Synthetic analgesics. I. Methadone isomers and deriva-
tives." J. Pharmacol. & Exper. Therap., 98 : 121-137, 19.50.

(104) Nathan B. Eddy. "Methadols and acetylmethadols." Read Lilly Research

Laboratories, May 24, 1951 : Pharmacological Institute, Basle, Switzer-
land, Nov. 15, 1951. Unpubli.shed.

(105) Nathan B. Eddy, Evekette L. May, and Erich Mosettig. "Chemistry and

pharmacologv of the methadols and acetylmethadols : XII." Interna-
tional Cong. Chem., New York, Sept. 7, 1951 : J. Org. Chem., 17 : 321-326.
1952.

(106) Nathan B. Eddy. "N-Allylnormorphine." Comm. Drug Addiction & Nar-

cotics. Jan. 21, 1952. Unpublished.

(107) "Drugs liable to produce addiction (The work of the World Health

Organization Expert Committees)." Public Health Reports, 61: 362,
1952.

(108) Nathan B. Eddy and Everette L. May. "The isomethadols and their acetyl

derivatives." J. Org. Chem., 17 : 210-215, 1952.

(109) Nathan B. Eddy, G. Robert Coatney, W. Clark Cooper and Joseph

Greenberg. "Survey of antimalarial agents." Public Health Monograph,
No. 9 : .323 pp. U.S. Govt. Print. Off., Washington. D.C. 1953.

(110) Nathan B. Eddy and Dorothy Leimbach. "Synthetic Analgesics: II. Di-

thienvlbutenyl- and dithienylbutylamines." J. Pharmacol. & Exper.
Therap. 107 : 385-393, 19.53.

(111) Nathan B. Eddy. "Heroin (diacetylmorphine). Laboratory & clinical

evaluations of its effectiveness and addiction liability." Bull. Narcotics,
5:39-44,1953.

(112) "Symposium on drug addiction: Foreword." Am. J. Med. 14'- 537,

1953.

(113) — "The hot plate method for measuring analgesic effect in mice." Na-
tional Research Council Bull. Drug Addiction & Narcotics, 603-612,
19.53. Unpublished.

(114) "Drug Addiction: Fact and Fancy." Royal Canadian Institute,

Toronto. Canada, Mar. 28, 19.53. Pro. Roval Canad. Inst., 18: 44, 19.53:
Health Ed. J., 17 : 1, 11 ; 17 : 2. 14-19, 19.53.

(115) Dorothy Leimbach and Nathan B. Eddy. "Synthetic analgesics: III.

Methadols, Isomethadols and their acvl derivatives." J. Pharmacol. &
Exper. Therap., 110 : 135-147, 19.54.

(116) Nathan B. Eddy. "The Phenomena of tolerance." Symposium on Drug

Resistance, Washington, D.C, Mar. 26, 1954. Published by Academic
Press — "Origins of Resistance to Toxic Agents." pp. 22.3-243* 1955.

(117) "The Committee on Drug Addiction and Narcotics." News Report,

National Academy of Sciences ; ^ : 93, 1954.

(118) Olav J. Braenden, Nathan B. Eddy, and H. Halbach. "Synthetic sub-

stances with morphine-like effect. Relationship between chemical struc-
ture and analgesic action." Bull. World Health Organization, 13: 937,
19.55.

(119) Nathan B. Eddy. "Addiction liability of nlagesics: tests and results."

Read, Symposium on alagesics, American Theraueptic Society, June 3,
19.55, Atlantic City, N.J. J. Am. Geriatrics Society, 4: 177, 19-56.

(120) "The search for new analgesics. Part of Symposium, Pain and its

relief." J. Chronic Dis., //.- 59, 1956.

(121) Nathan B. Eddy, II. Haibach, and Olav J. Brafndex. "Synthetic sub-

stances with morphine-like effect. Relationship between analgesic action
and addiction liability, with a discussion of the chemical structure of
addiction producing substances." Bull. World Health Organization, 14:
.353. 1956.

(122) Nathan B. Eddy. "Synthetic narcotic drugs." Union Signal, 82: 7, 19r.5.

(123) Theodore D. Perrine and Nathan B. Eddy. '"The preparation and anal-

gesic activity of 4-carbethoxy-4-pheuyl-l-(2-phenyIetliyl) -piper idine and
related compounds." J. Org. Cheni., 21: 12.j, ID.jH.

(124) Nathan B. Eddy. "Habit-forming drugs." Bull. Drug Addiction & Nar-

cotics, p. 1494. 195«;.

(125) "The history of the development of narcotics." Law and Contempo-
rary Problems, 22: 3, 1907.

(12G) "Addiction-producing versus habit-forming." Guest editorial J. Am.

Med. Assn., 163: 1G22, 1957.

(127) "New developments in analgesics." Read, Bahamas Medical Con-
ference, Nassau, Apr. 25, 1957. Unpublished.

(128) "Addiction — ^the present situation." Read, Bahamas Medical Con-
ference, Nassau, Apr. 25, 1957. Unpublished.

(129) Nathan B. Eddt, H. Halbach, and Olav J. Braenden. "Synthetic sub-

stances with morphine-like effect. Clinical experience : Potency, side
effects and addiction liability." Bull. World Health Orgn., 27; 569, 1957.

(130) Nathan B. Eddy, James G. Murphy, and Everette L. May. "Structures

related to morphine : IX. Extension of the Grewe morphinan synthesis
in the benzomorphan series and pharmacology of some benzomorphans."
J. Org. Chem., 22: 1070, 1957.

(131) Nathan B. Eddy, Red wig Besendorf, and Bela Pellmont. "Synthetic

Analgesics : IV. Aralkyl substitution on nitrogen of morphinan. "U.N.
Bull. Narc. 10: (No. 4) , 23, 1958.
(131a) Lyndon F. Small. Nathan B. Eddy, J. Harrison Ageu. and Everette L.
May. "An improved synthesis of N-phenethylnormorphine and analogs."
J. Org. Chem., 23: 1387, 1958.
1 132) Nathan B. Eddy and Lyndon E. Lee, Jr. "The analgesic equivolence to
morphine and relative side reaction liability of oxymorphone (14-hy-
droxy-dihydromorphinoue)." J. Pharmacol. & Exper. Therap., 125: No. 2,
February 1959.

(133) Nathan B. Eddy, Lyndon E. Lee, Jr., and Cari. A. Harris. "The rate of de-

velopment of physical dependence and tolerance to analgesic drugs in
patients with chronic pain : I. Comparison to morphine, oxymorphone
and anileridine." Bull. Narc, 11: Nos. 1, 3, 1959.

(134) Nathan B. Eddy and Harris Isbell. "Addiction liability and narcotics

control." Public Health Reports, 7.J; 755, September 1959.

(135) Nathan B. Eddy. "Chemical structure and action of morphine-like anal-

gesics and related substances." Sixth Lister Memorial Lecture. Chem. &
Indust., 47.- 14H2 November 1959.

(136) Nathan B. Eddy, Lyndon E. Lee, Jr., and Carl A. Harris. "Dependence

physique et tolerance vis-a-vis de certains analgesiques chez des malades
souffrant de douleurs chroniques. Comparison entre la morphine, I'oxy-
morphoneet I'anileridine." Bull. Org. Sante, 20: 1245, 1959.

(137) Nathan B. Eddy, Modeste Piller, Leo A. Pirk, Otto Schrappe, and

SiGUARD Wende. "The effect of the addition of a narcotic antagonist on
the rate of development of tolerance and physical dependence to mor-
phine." Bull. Narc, 12: No. 4, 1959.

(138) Everette L. May and Nathan B. Eddy. "A new potent synthetic anal-

gesic" J. Org. Chem., 2J,: 294, 1959.

(139) Everette L. May, and Nathan B. Eddy. "Structures related to morphine:

XII. ( ± ) -2'-Hydroxy-5,9-dimethyl-2-phenethyl-6,7-benbomorphan ( NIH-
7519) and its optical forms." J. Org. Chem., 24: 1435-1437, 19.59.

(140) Paul A. J. Janssen and Nathan B. Eddy. "Comiwunds related to pethi-

dine : IV. New general chemical methods of increasing the analgesic
activity of pethidine." J. Med. Pharmaceut. Chem., 2: 31. I»i0.

(141) J. R. Nicholls and Nathan B. Eddy. "The assay, characteristics, compo-

sition and origin of opium. No. 97. Analysis of samples of opium of
unknown origin." United Nations, ST/SOA/Ser. K/97, February 19,
1960.

(142) BENJAJfiN J. CiLiBEKTi AND Nathan B. Eddy. "Preanesthetic medication:

morphine, anileridine, oxymorphone, and placebo." Bull. Narc, 13 : Nos.
3, 1, 1961.

(143) Everette L. May and Nathan B. Eddy. "The assay, characteristics, com-

position, and origin of opium. No. 111. The analysis of authenticated
opium samples bv means of direct absorption spectrophotometry." United
Nations, ST/SOA/Ser. K/Hl, October 6, 1961.

<144) Nathan B. Eddy, H. M. Fales, E. Haahti, P. F. Highet, E. C. Horning,
E, L. May, and W. C. Wildman. "The assay, characteristics, composi-
tion, and origin of opium. No. 114. Identification and analysis of opium
samples by linear-programed gas chromatography." United Nations,
ST/SOA/Ser.K/114, Oct. 6, 1961.

(145) Maxwell Gordon, John J. Laffebty, David H. Tedeschi, Nathan B.

Eddy, and Everette L. May. "A new potent analgetic antagonist." Na-
ture, 192 : 1089. 1961 .

(146) Maxwell Gordon, John J. Lafferty, Blaine M. Sutton, David H.

Tedeschi, Nathan B. Eddy and Everette L. May. "New benzomorphan
analgetics." J. Med. Pharmaceut. Chem., 1962. In press.

(147) Nathan B. Eddy and Hans Halbach. "Synthetic substances with mor-

phine-like effect: V. Tests for addiction." Bull. World Health Organi-
zation, 1962. In press.

(148) Nathan B. Eddy and Everette L. May. "Synthetic Analgesics, Part 2, B.

Benzomorphans" Pergamon Press, 1962. In press.

(149) H. Halbach and Nathan B. Eddy. "Tests for addiction (chronic intoxi-

cation) or morphine type." Bull. World Health Organization, 1963,
28 : 139

<150) Nathan B. Eddy. "Statement on Relative Safety of Codeine Prepara-
tions." Read, Senate Committee on Judiciary, California Senate, Sacra-
mento, Calif., Mar. 8, 1963.

(151) — ^ "The role of the National Academy of Sciences and the National

Research Council." Proceedings White House Conference on Narcotic and
Drug Abuse, Washington, D.C., Sept. 27-28, 1962, p. 136.

(152) "The chemo-pharmacological approach to the problem of drug ad-
dition." Read, Conference on Drug Addiction, University of California
at Los Angeles, Apr. 27-28, 1963. U.S. Public Health Report (1963) 78:
673. Proceedings of the conference. McGraw-Hill (1964). In press.

(153) Nathan B. Eddy, B. Ciliberti, and Phyllis F. Shroff. "Preanaesthetic
medication." Bull. Narcotics (1964) 16 : No. 2, 41.

<154) Nathan B. Eddy. "Drug addiction and the law." Britannica Book of the
Year (1964), 291.

(155) "The search for a nonaddicting analgesic." Proc. of symposium on

history of narcotic drug addiction problems. Mar. 27-28, 1958. Public
Health Service publication No. 1050, U.S. Gov. Print. Off. (1963).

Chairman Peppp:e. We will now take a 5-minute recess.

(A brief recess was taken.)

Chairman Peppee. The committee will come to order, please.

Dr. Brill, would you please come forward.

Our next witness today is Dr. Henry Brill, ca distinguished psychia-
trist and hospital administrator.

Dr. Brill, a graduate of Yale College and Yale Medical School,
served his internship at Pilgrim State Hospital in New York, the
same facility that he now serves as director.

Dr. Brill is a diplomate of the American Board of Neurology and
Psychiatry, a fellow of the American Psychiatric Association, and a
certified mental hospital administrator.

He has served as assistant commissioner for research and medical
services of the New York Department of Mental Plygiene : and vice
chairman of the New York State Narcotic Addiction Control
Commission.

PTe has been director of Pilgrim State Plospital, with time out for
some of his other appointments, since 1958.

Dr. Brill has served as clinical professor of psychiatry at Albany
Medical College and as professional lecturer at Upstate Medical Cen-
ter in Syracuse, N. Y.

He is presently a lecturer in psychiatry at Columbia Uiiiversity-s
College of Physicians and Surgeons, and clinical professor of psychia-
try at the New York School of Psychiatry.

In the past, Dr. Brill has served as president of both the American
College of Neuropsychopharmacology and the Eastern Psychiatric
Research Association. He is currently president-elect of the American
Psychopathological Association.

In addition to serving on the editorial boards of four scientific jour-
nals, Dr. Brill is a member and past chairman of the American Medi-
cal Association's Committee on Drug Dependence and Alcoholism; a
member and past chairman of the National Research CounciFs Com-
mittee on Drug Dependence, and was recently appointed to the Presi-
dent's Commission on Marihuana and Drug Abuse.

In 1965, Dr. Brill was chairman of the methadone maintenance
evaluation advisory committee of the Columbia School of Public
Health.

I have taken the time to list but a few of Dr. Brill's many profes-
sional appointments and accomplishments. I will not detail the over
100 papers in the field of psychiatry, administration, somatic theory,
and drug dependence he has authored.

Dr. Brill, we are greatly honored that you have taken time from
your busy schedule to share your immense knowledge with us.

Mr. Perito, would you make the inquiries ?

Mr. Perito. Thank you, Mr. Chairman.

Dr. Bril], I understand you have a prepared statement ?

STATEMENT OE DE. HENEY BRILL, DIRECTOR, PILGRIM
STATE HOSPITAL, NEW YORK, N.Y.

Dr. Brill. I have.

Mr. Perito. Would you care to read that statement or just sum-
marize it?

Dr. Brill. I would like to skip through it because much of it re-
peals what you have already heard this morning.

Chairman Pepper. Doctor, without objection, your full statement
will appear in the record, and you may give such summary of it as you
will.

Dr. Brill. Thank you, sir.

I think what I would like to stress here is that the question before
your committee, as has been mentioned, was already brought up in
1051, but it is different in one important respect. In 1951, the question
was asked what would happen in a state of national emergency when
stocks of opiuni derivatives were exhausted and not to be replenished.
Now, today this Nation is in a secure position with respect to such an
emergency, and I think that you already have heard that we haA-e good
substitutes under such circumstances so there would be no emergency
in the medical practice if the supplies were cut off.

I would also like to point out that this is, to a significant degree, the
direct result of a major coordinated research in which the iSTational
Academy of Medicine-National Research Council Committee played
an important role under the leadership of Dr. Nathan Eddy, who was
its chairnian for most of the time, since 1951, and I might also add that
another important element was the work of Dr. Maurice Seevers, whom
you have heard this morning.

You now, as I understand it, are interested in the situation with re-
spect to a complete substitution in a nonemergency situation, and this

entails the consideration of additional important factors, factors in
jiddition to those coiisidered in response to the first question: That is
the established patterns of medical and pharmaceutical practice, and
I might add. it also relates to the habits of the public with respect to
the medication they take, because one of these medications- codeine,
is extensively self-administered for the treatment of cou^h.

From all ])ersonal experience, I am led to believe that tlie synthetics
are playing a large and growing role in the practice of medicine, yet
it appears the natural opium products and their derivatives are still
extensively used in spite of the availability of heavily advertised syn-
thetic rei)lacements, and these synthetics are being heavily advertised
in the medical press at least. The TT.N. publication "Statistics on Nar-
cotic Drugs for lOGO." table o, indicates that the amou.nt of morphine
converted into '^odeine actually rose worldwide from 112.350 kilo-
grams in 1905 to 146,000 kilograms in 1969, and the corresponding
U.S. figures rose from 20,000 kilograms to 28,000 kilograms, v.-hir>h
points to a marked public acceptance of the use of codeine in current
practice.

The increases were irregular, but the figures seemed to show that
the natural products, and especially codeine, continue to play a very
large role in world medicine and in the United States, and that the
U.S. share is significant but by no means decisive in the overall figures.

It would thus seem that in a plan to influence the dru<i' dependence
field by terminating the use of natural products would call for re-
orientation of this aspect of medical practice within the Ignited States
and in other countries as well. Quantitativelv the story relates to co-
deine. The issue which would have to be considered includes the relative
costs of the natural and synthetic products and the relative familiarity
of public and the health professions with the many characteristics of
each of the various drugs because in practice few drugs are entirely 07-
essentially identical. They tend to vary among themselves as to speed
and duration of their primary action and the relative intensity and
timing of their many other properties. From all available information,
it would seem that a replacement is technically feasible Init it would
also appear that this would call for full considtation with organized
medicine and pharmacy. In order to be fully accepted, such a transition
would require further research to explore the many pharmacological
characteristics of the substitute drugs — and this includes the question
of teratogenicity, which is a thorny question at the present moment,
the capacity to create deformities in unborn children — in the multi-
plicity of clinical situations and the many conditions under which the
drugs are used and this would call for extensive laboratory studies
and clinical investigations. Because when a drug comes out of a labora-
tory and comes into clinical practice there is a large empirical element
that must enter into it, because no laboratory can ever go into all the
various complex situations that are liable to be faced in actual mcMlical
practice. They can approximate it, but they can't totally reproduce it.

I appreciate the opportunity to appear before this body and realize
that there is room for nnich clifference of opinion on all these matters
but have sought to identify the prol)loms which would seem to require
solution in connection with the proposal which is before you. Under
emergency conditions the synthetic drugs which we now have would
fully replace the natural products in control of i^ain and for other

indications but under nonemergency conditions it would seem that
the immediate reorientation of medical and pharmaceutical procedures,
on the scale implied in the U.S. figures, would require a major effort,
although there are strong indications that the long-term trend lies in
this direction, that is, in the direction of the gradual substitution of
he natural products by the introduction of synthetics.

Thank you, sir.

Chairnian Pepper. Doctor, what needs to be done, in addition to what
has already been done, to justify Congress in prohibiting the impor-
tation of any deri^'ati\'GS of opium so as to lead to the stoppage of the
growing of the opium poppy ? Do you think additional research is nec^
essary, and if so, are additional funds required ? What more needs to
be done^

Dr. Brill. I would say yes to both counts. For example, a synthetic
way of producing codeine which hasn't yet been achieved or a synthetic
which will substitute completely for codeine — and we do not have a
drug which is exactly like codeine — both of these would be well worth-
while in connection with the proposal, and they call for research.

In addition, if I may, there is a large amount of investigation that
needs to be done and has not been done in connection with many, many
interesting products that have been tested and are available for fol-
lowup but have not been thoroughly investigated because of a lack of
funds.

Chairman Pepper. Doctor, what do you consider the state of develop-
ment of antagonistic drugs to heroin addiction?

Dr. Brill. I think we are at the beginning, sir. Naloxone is one drug
which is quite acceptable to those patients who are willing to take the
antagonist and the supply is as yet not extensive. I think that this is
now being developed, but we need a substance which will have a longer
action tlian naloxone has. But I must also point out that many pa-
tients will refuse to take, many addicts will refuse to take, antago-
nists. This is from my personal experience.

Chairman Pepper. Are you informed about the methadone experi-
ment in New York '?

Dr. Brill. , Yes.

Chairman Pepper. "Would you comment on the use of methadone in
the treatment of heroin addiction?

Dr. Brill. When methadone is used along the lines that Dr. Eddy
outlined, when it is properly used in a program of treatment, it can
produce results which I think are better than any other techniques
that I know for a certain number of addicts whose condition is intrac-
table to any other procedure. But when methadone is used by other
methods, by other techniques and in other ways, it can become a pub-
lic health hazard and the essential difference between the medical use
of methadone and the abuse of methadone is that the medical use of
methadone provides physical saturation, saturation of the physical
need but it produces no mental effect. "Whereas, if the drug is used in
such a way as to produce mental effects it produces all the harm of ad-
diction as we know it. It produces mental effect when it is injected in-
travenously and when it is taken orally by beginners on an irregular
basis.

Chairman Pepper. Have you found tliat the use of methadone in the
New York experiment with which you are familiar has reduced the
amount of crime committed by the heroin addict treated ?

Dr. Brill. In the cases that are under treatment, the statistics are
quite spectacular. The amount of crime was reduced by over 85 per-
cent. But I cannot say that there was an impact on the overall crime
statistics, althou<ili I knoAv how difficult it is to eA^aluate overall
crime statistics. But among the population that followed the metha-
done treatment, the reduction in crime is spectacular.

Chairman Pepper. Mr. Perito, do you have any questions of Dr.
Brill?

Mr. Pertto. a couple of brief ones, Mr. Chairman.

Dr. Brill, how would it be best to coordinate the eflForts of or-
ganized medicine to move toward the use of synthetic analgesics ?

Dr. Brill. You mean to advance the use of existing synthetics or
new synthetics ?

Mr. Perito. Existing synthetics.

Dr. Brill I think an educational program would be useful. I think
there is relatively little problem, as Dr. Eddy pointed out, in connec-
tion with the use of synthetics for the control of pain in connection
with operations and major surgery or major accidents and this kind
of thing.

The real problem is in the use of codeine as an analgesic and an
antidepressant for the control of cough. Hero the drug has a combi-
nation of qualities that are not easily mimicked.

Mr. Perito. Would you acquiesce in the judgment of Dr. Eddy that
methadone should not be distributed by private physicians but should
only be distributed in a coordinated clinical atmosphere with proper
support services?

Dr. Brh^l. Most certainly.

Chairman Pepper. Mr. Mann.

Mr. Mann. No questions, Mr. Chairman.

Chairman Pepper. Mr. Wiggins?

Mr. Wiggins. Doctor, your testimony indicated that one of the
problems with the synthetics is that they have not been thoroughly
tested to know fully their impact in general clinical use. But isn't
it so. Doctor, that many of these substitutes are now in clinical use ?

Dr. Brill. Yes, sir ; they are. Unfortunately, it takes years of clinical
use before all the ramifications of a drug can be identified. For exani-
ple, we take one of the commonest drugs in clinical use, and that is
tobacco. It was in clinical use for hundreds of years before anyone
suspected that it might possibly lead to pathologies in the lungs and
so on. So the same has happened over and over again with ncAvly
introduced drugs. After they have been on the market for a while,
questions have been raised.

Antidiabetic drugs recently had questions raised about them which
are not fully answered as yet. It is a controversial subject, as you know.

So the fact that a drug is in clinical use is reassuring, but not totally
reassuring.

Mr. Wiggins. Doctor, simply because questions exist and probably
will always exist, are you satisfied that those questions standing alone
are sufficient reason not to warrant a statute which would outlaw
morphine and thereby force the general clinical use of the substitute ?

Dr. Brill. I think there would be less difficulty with a statute out-
lawino: morphine than with a statute outlawing all opium products.
I think it would be relatively simple to outlaw morphine, although
there would be, as has been brought out here, professional questions
raised both on the grounds of familiarity with the morphine and on
the grounds that there is a reluctance to have such things legislated.
But this is not, as I see it, the major problem.

Mr. Wiggins. The point was made by Dr. Eddy that the medical
profession would require a period of orientation and education. How
long do you suppose would be appropriate for that purpose?

Dr. Brill. If I might add to that question, it might be well to allow
organized medicine to come in and make its comments.

Mr. Wiggins. They will be invited to do so.

(See Exhibit 1.)

Dr. Brill. Yes.

Chairman Pepper. Yes.

Dr. Brill. I hesitate to speak for organized medicine, but it cer-
tainly couldn't be done in less than several years to the satisfaction of
most people.

Mr. Wiggins. That is all the questions I have.

Chairman Pepper. Mr. Steiger?

Mr. Steiger. Thank you, Mr. Chairman.

Doctor, the summation of your testimony and that of Dr. Eddy and
Dr. Seevers is that there is no medical reason for retaining the natural
analgesic, whatever the medical term is. Now, Doctor, as a layman, it
occurs to me that we have had painted here this morning a rather un-
flattering picture of the medical profession, because we say we arrive
on a conclusion based on a question posed in 1951, the conclusion being
that in a physical emergency in which opium was not available the
medical profession could readily adjust. Now, we understand, and
rather thoroughly, from the testimony that it would be, one, inconven-
ient and it would be what is termed justifiable for natural resistance
to any change, it would be difficult to stop cough.

Now, I think, it seems to me unfair to the medical profession — I
wouldn't want to just leave it lying there — that the inconvenience, the
comfortable familiarity with the existing natural opiates, all of these
things of themselves are so important that the evils that the opiate
now represents are going to be somehow set aside. It would be easy for
those of us in the political arena — and I am sure some of us will — to
call this an emergency situation. We truly have an emergency. There
are many areas in which the emergency is very genuine. The chairman,
I think, defined it pretty well at the outset.

I would hope that possibly — obviously the most comfortable thing
for us, and we are interested in our comfort, too — would be for the
medical profession to come forth and say now is the time and for the
medical profession to declare this an emergency and for the medical
profession to say these synthetics work, they will use them, those who
have coughs will perhaps have to cough a little.

I don't honestl}'^ know what the clinical situation is. But I know
that, again, just having heard this and having considered myself a
friend of medicine, I think we are painting medicine accurately, per-
haps, but unfairly nevertheless.

56^.

I wonder would you care to comment, and I suspect it is rather un-
fair, but on the likelihood of the medical profession feeling the need
to come forward and say let's do this thing.

Dr. Brill. I think that the real issue is the feeling of the public. The
medical pi-ofession can only represent the patient in this area, because
the doctor deals with a patient, and the indications for the use of
codeine, for example, are not indications of life and death. They are
relatively minor indications.

But I think all any technical person can do is to venture an opinion
as to whether a drug can be fully substituted to the satisfaction of the
patient or whether the substitution will not be equally satisfactoiy to
the patient. I think it would be misleading, from my point of view, if
I were to say that in my opinion drugs wdiich would replace codeine
would be just as satisfactory to the patient as codeine now is, particu-
larly keeping in mind that much of the codeine is over the counter
where the physician doesn't enter into it at all.

But the bar is not an absolute bar. It is a question of cost-benefit
ratios, and T am not in a position to judge the benefits. I think these
benefits have to do with traffic and so on, which I don't know anything
about.

Mr. Steiger. I understand. All right.

Medically, Doctor, on a scale of 1 to 10, how effective — and putting
codeine at 10 — how effective are the known codeine substitutes for
cough suppressants on this scale of 1 to 10, and would that be sufficient
to make the abolishment of opium and Avhatever benefits would derive
on a national basis? Really, I guess that is what we are faced with.
Obviously we don't want to impose a genuine hardship on the public.
By the same token I have great faith in the medical profession being
able to convince the public that what we are prescribing for them is
good for them, even though that may not always be the case.

On that 1 to 10 ratio, what would you say ?

Dr. Brill. Well, as a rough guess I would say two or three.

Mr. Steiger. So in your opinion that is where the gap lies, then ?

Dr. Brill. There is a possible difference, and there also is a possible
difference between the usefulness of codeine as an analgesic in many
cases and the usefulness of the competing analgesics. I think it is
less clear cut. These are matters of judgment and opinion and not
easily measured. But I think there is that difference.

But I must again say that much of this codeine, I don't know what
proportion — you easily can find out — much of the codeine used has
no medical intervention at all. This is a matter of public habit.

Mr. Steiger. I must say is not used medically ?

Dr. Brill. There is abuse of the cough mixtures. That is true. There
also is abuse of synthetic cough mixtures. So that is an even tossup.

Mr. Steiger. I thank you.

Chairman Pepper. ^Ir. Blommer, any questions?

Mr. Blommer. No, Mr. Chairman.

Chairman Pepper. Mr. Winn?

Mr. WixN. None, Mr. Chairman.

Chairman Pepper. INIr. Keating?

Mr. Keating. None, Mr. Chairman.

Chairman Pepper. Dr. Brill, I think you have given us extremely
valuable testimony this morning. You know, sometimes we can be
pushed a little bit to get to the conclusions that we want to reach.

I very much sympathize with what was suggested by Mr. Steiger.

Is codeine used largely in the suppression of cough?

Dr. Brill. Suppression of cough and for the control of minor pains
and minor discomforts. It is an analgesic.

Chairman Pepper. Yv e hope to iiear later from the medical associa-
tion and the whole medical profession on this subject. We w^ould cer-
tainly hope that they would take the lead in trying to move as rapidly
as possible, because Congress is faced with such a terrible problem in
heroin addiction. I believe we all agree that it is growing worse;
isn't it i (See Exhibit No. 1 for AMA views.)

Dr. Brill. Yes, sir ; it is.

Chairman Pepper, ilie problem is so serious, and it seems impossible
to stop it by law enforcement, which catches only 20 percent of the
heroin being smuggled into this country. That method seems so im-
probable of success that we have to turn to alternatives to see what
else we can do.

Dr. Brill. I agree.

Chairman Pepper. That is the reason we are trying to get teclmical
information, scientific knowledge that would guide the Congress in
seeing whether or not we may safely and properly move in this direc-
tion of stopping importation of opium. If we could stop the legal
growing of the opium poppy it would be easier to police a ban. We
could catch it, then.

Dr. Brill. Thank you.

Chairman Pepper. Mr. Perito has one more question?

Mr. Perito. Dr. Brill, have you had an opportunity, in your pro-
fessional practice, to treat and evaluate addicts who have been given
antagonists ?

Dr. Brill. Yes.

Mr. Perito. What is your professional opinion about the possibili-
ties of developing antagonists to the point w^here they will become an
effective weapon o^ the clinician in the treatment of drug-dependent
persons ?

Dr. Brill. I think it is a very good possibility and a very excellent
lead to follow. I wouldn't want to leave the impression that this is a
panacea, but the antagonists certainly are one of the best leads that
I know of.

Chairman Pepper. Are more funds necessary, in your opinion, to
carry on the developmental work in the finding of these solutions for
opium derivatives and finding antagonistic drugs to heroin addiction ?

Dr. Brill, Yes, sir; to my personal knowledge many of the most
important research activities in the country today in this field are
feeling the pressure of shortage of funds, and I think that this is
something that I have to call to your attention.

Chairman Pepper. The Federal Government might well interest
itself in providing more funds ?

Dr. Brill. I think so.

Chairman Pepper. Anything else ?

Mr. Perito. Mr. Chairman, may we have incorporated in the record
Dr. Brill's prepared statement; also, Dr. Brill's curriculum vitae.

60-296 O — 71— pt. 1 5

Chairman Pepper. Without objection, they will be admitted.
Thank you very much Doctor, for coming today.
(The material referred to follows :)

[Exhibit No. 5(a)]

Prepared Statement of Dr. Henry Brill, Director of Pilgram State

Hospital, New York, N.Y.

On the feasibility of replacing natural opium products with totally
synthetic substances in medical practice.
Mr. Chairman and Members of the Committee: I am Dr. Henry Brill of
Brentwood, N.Y., and a member of the committee on alcoholism and drug de-
pendence of the American Medical Association and the Committee on Problems
of Drug Dependence of the National Research Council. I am also immediate past
chairman of both committees and a member of the World Health Organization
Expert Committee on Drug Dependence. However, my statement here today is
made in a purely personal capacity and I am not here as a representative of any
group or organization.

I believe you already have testimony to the effect that as long ago as 19ol, the
Committee on Drug Addiction and Narcotics (now the Committee on Problems
of Drug Dependence), National Academy of Science-National Research Council
was questioned about the possibility of completely replacing natural opium
products with synthetic substances in the practice of medicine. The answer at
that time was a qualified affirmative and, as you know, the answer today has
become an unqualified aflSrmative. With this I fully concur and agree that from
the scientific and pharmacological point of view, such a substitution is entirely
practicable.

The question now before your group is different from that which was posed
in 1951. That question related to a state of national emergency in which it was
assumed that stocks of opium were exhausted and irreplenishable. Today this
Nation is, I believe, in a secure position with respect to such an emergency and
this improvement is to a significant degree the direct result of a major coordi-
nated research effort in which the National Academy of Medicine-National Re-
search Council Committee played a prominent role under the leadership of Dr.
Nathan Eddy who was its chairman for most of that time.

You are now interested in the situation with respect to a complete substitu-
tion in a nonemergency situation and this entails consideration of an important
factor in addition to those considered in response to your first question and I
refer to the established patterns of medical and pharmacological practice.

From all personal exi^erience, I am led to believe that the synthetics are play-
ing a large and growing role but yet it appears that the natural opium products
and their derivatives are still extensively used in spite of the availability of
heavily advertised synthetic replacements. The U.N. publication "Statistics on
Narcotic Drugs for 1969," table 5, indicates that the amount of morphine con-
verted into codeine actually rose worldwide from 112,350 kilograms in 1965 to
146,084 kilograms in 1969 and the corresponding U.S. figures rose from 20,089
to 23,084 kilograms. The increases were irregular but the figures seem to show
that the natural products continue to play a very large role in world medicine
and in the United States and that the U.S. share is significant but by no means
decisive in the overall figures.

It would thus seem that any plan to influence the drug dependence field by
terminating the use of natural products would call for reorientation of this
aspect of medical practice within the United States and in other countries as
well. The issue which would have to be considered includes the relative costs
of the natural and synthetic products and the relative familiarity of public and
the health professions with the many characteristics of each of the various
drugs because in practice few drugs are entirely or e.'^sentially identical. They
tend to vary among themselves as to speed and duration of their primary action
and the relative intensity and timing of their many other properties. From all
available information, it would seem that a replacement is technically feasible
but it would also appear that this would call for full consultation with organized
medicine and pharmacy. In order to be fully acceptable, such a transition
would require further research to explore the many pharmacological character-
istics of the substitute drugs in the multiplicity of clinical situations and the

many conditions undef which the drugs are used and this would call for ex-
tensive laboratory studies and clinical investigations.

I appreciate the opportunity to appear before this body and realize that there
is room for much difference of opinion on all these matters but have ;;ought
to identify the problems which would seem to require solution in connection
with the proposal which is before you. Under emergency conditions the synthetic
drugs which we now have would fully replace the natural products in control
of pain and for other indications but under nonemergency conditions it would
seem that the immediate reorientation of medical and pharmaceutical procedures,
on the scale implied in the U.N. figures, would require a major effort although
there are strong indications that the long-term trend lies in this direction.

[Exhibit No. 5(b)]

Curriculum Vitae of Dr. Henry Brill, Director, Pilgrim State

(N.Y.) Hospital

1906 Born Bridgeport, Conn.

1928 Graduate Yale College.

1932 Graduate Yale Medical School.

1932-34 Medical intern Pilgrim State Hospital (recognized as basis

for Nat. Board Part III).

1934 Licensed New York State (28727) .

1938 Diplomateof National Board (by exam) (6160).

1938 Qualified psychiatrist, New York State.

1940 Diplomate of American Board of Neurology and Psychiatry.

1951 Fellow American Psychiatric Association.

1957 Certified Mental Hospital Administrator (412) .

1934-50 Resident, Senior Psychiatrist, Clinical Director and Associate

Director, Pilgrim State Hospital.

1950-52 Director, Craig Colony and Hospital (epilepsy) .

1952-59 Assistant Commissioner for Reserach and Medical Services,

Department of Mental Hygiene, New York.

1958-64 (Director, Pilgrim State Hospital — on leave).

1959-64 Deputy and First Deputy Commissioner, N.Y. State Depart-

ment of Mental Hygiene (Special reference to Research
Training and Medical Services).

1964-66 Director Pilgrim State Hospital.

1966-68 Vice Chairman NY State Narcotic Addiction Control Com-

mission (Director — on leave — P.S.H.).

1968 to date Director Pilgrim State Hospital.

teaching

1955-64 Associate Clinical Professor and Clinical Professor — Psychia-

try— Albany Medical College.
1958-64 Professional lecturer — Upstate Medical Center, Syracuse.

1958 to date Lecturer — Psychiatry — College of Physicians and Surgeons,

Columbia University.

1959 to date Clinical Professor of Psychiatry, New York School of Psy-

chiatry.

1964-68

ORGANIZATIONAL

Past President of American College of Neuropsychophar-

macology and of Eastern Psychiatric Research Association.
Currently President-Elect American Psychopathological

Association.
Elected to Council of American Psychiatric Association;

Council Representative to Committee on Mental Hospital

Standards and Practices.

EDITORIAL BOARD

1948 to date Psychiatry Quarterly.

1968 to date International Journal of Addictions.

1969 to date Psychopharmacologia.
1971 to date Comprehensive Psychiatry.

1958-68

1959-«4

1969

1962-64

1962

1969
1965

1970

1971

COMMITTEES

Member and Chairman of Advisory Committee Clinical Psy-
chopharmocolgy NIMH.

Member and Chairman A.P.A. Committee on Nomenclature
and Statistics (DSM II).

Chairman of American Psychiatric Association Task Force
on Nomenclature and Statistics.

Member of Subcommittee on Classification to U.S. Surgeon
General.

Consultant to World Health Organization — Statistics and No-
menclature (Psychiatry).

Member and past chairman of A.M.A, Committee on Drug De-
pendence and Alcoholism.

Member and past chairman of National Research Council —
Committee on Drug Dependence.

Member W.H.O. Expert Committee on Drug Dependence.

Chairman — Methadone Maintenance Evaluation Advisory
Committee Columbia School of Public Health.

Member of NY State Regents Committee on Continuing Edu-
cation

Member of Presidential Commission on Marihuana and Drug
Dependence

On various Advisory Committees — Department of Justice,
FDA, and NIMH.

1970
1970

PUBLICATIONS AND HONORS

Author of over 100 papers in the field of Psychiatry, Admin-
istration, Somatic Therapy and Drug Dependence.
Member of Sigma XI and Phi Beta Kappa.
Recipient Hutchings Award.
Listed in current "Who's Who in America."

Chairman Pepper. Secretary Rossides, please.

The committee is pleased to call now the Honorable Eugene T. Ros-
sides, Assistant Secretary of the Treasury for Enforcement and
Operations.

Mr. Rossides serves as the principal law enforcement policy advisor
to the Secretary of the Treasury. His responsibilities include provid-
ing policy guidance for all Treasury law enforcement activities, as
well as direct supervision of the Bureau of Customs, the U.S. Secret
Service, the Bureau of the Mint, the Bureau of Engraving and Print-
ing, the Consolidated Federal Law Enforcement Training Center, the
Office of Operations, the Office of Tariff and Trade Affairs, and the
Office of Law Enforcement.

Mr. Rossides also serves as U.S. Representative to Interpol, the in-
ternational criminal police organization, and was elected one of three
vice presidents of Interpol in October 1969.

From 1958 to 1961, he served as Assistant to Treasury I'nder Secre-
tary Fred C. Scribner, Jr. Early in his law career, Mr. Rossides served
as a criminal law investigator in the rackets bureau on the staff of Xew
York County District Attorney Frank S. Hogan. For 2 years, he was
an assistant attorney general for the State of XeAv York, assigned to
the bureau of securities to investigate and prosecute stock frauds. A
former legal officer for the Air Materiel Command, Mr. Rossides holds
the reserve rank of Air Force captain.

A native of New York, Mr. Rossides received his A.B. degree from
Columbia College and his law degree from Columbia Law School.

Mr. Rossides is a vice president of the New York Metropolitan
Chapter of the National Football Foundation and Hall of Fame and
a director of the Touchdown Club of New York.

Mr. Rossides, it is indeed a pleasure to have you with us today. Al-
though your responsibilities are widespread, I understand that you
are going to limit your testimony today to the role of the Bureau of
Customs in controlling the illicit flow of heroin into the United States
and your support for this committee's proposal for an international
ban on opium cultivation.

Mr. Perito, will you inquire ?

Mr. Perito. Secretary Rossides, I understand you have a prepared
statement ?

STATEMENT OF EUGENE T. KOSSIDES, ASSISTANT SECRETARY OF
THE TREASURY, ENFORCEMENT AND OPERATIONS

Mr. Rossides. Yes ; I do.

Mr. Perito. Would you care to present that to the committee ?

Mr. Rossides. Mr. Chairman, members of the committee, it is a great
pleasure to appear again before this committee.

I think this committee has done some of the most significant work
that has been done in Congress in this area of narcotics — in the total
area of the narcotics problem.

I am pleased to be here today. I will summarize my statement and
read the key paragraph regarding the committee's inquiry.

Mr. Chairman and members of the committee, I am pleased to be
here at the request of the committee to give my views on a narrow but
significant question ; namely, what would be the enforcement effect if
there were an adequate supply of synthetic substitutes for opium and
substances derived from opium. Put another way, would it be helpful
in preventing the illegal growth and diversion of opium and the prod-
ucts of heroin and its smuggling into the United States. As back-
ground, let me say that there are at least five critical points in the ille-
gal narcotics traffic:

( 1 ) The growth of opium poppies ;

(2) Illegal diversion of opium;

(3) Illegal production of morphine and heroin ;

(4) Smuggling into the United States ; and

(5) Distribution within the United States.

I have testified before this committee regarding the President's six-
point action program. I think the President has by his personal inter-
vention and initiatives elevated the drug problem to a foreign policy
level. His White House conferences and other efforts devoted to this
problem have alerted not just the international community but the
national community as well. His efforts have stimulated debate, re-
search, education, and enforcement and have recognized the role of the
States and the role of the private community in dealing with the nar-
cotics problem. The private community under discussion here today,
and the medical profession particularly, have an enormous role to play
in this whole problem.

This doesn't mean more should not be done. But I do feel, and it is
my own personal judgment, that the President's action program has
alerted the international community to the global problem of drug

abuse and has brought about the action needed to combat it; and on
the national scene, has arrested our incredible downward slide into
drug abuse.

As I have testified before, however, let there be no false optimism.
This simply means we have stopped the downward trend, turned it
around, and have a long way to go to come back to the level at which
we would like to be.

I am confident we Avill meet that challenge, because it has become a
national bipartisan effort. The Congress has an essential role as does
the executive in this entire area. The private community has a role.
The States have the central role in law enforcement, in the distribu-
tion of needed information, in education, and indeed they might do
more in research.

With this background, Mr. Chairman and members of the commit-
tee, I would answer the committee's inquiry by stating that in enforce-
ment terms the ban on opium production as a legal item would be a
definite plus. When there is no legal growth of poppies permitted, the
enforcement officials will clearly have a much easier time in locating
illegal acreage.

Secondly, when there is no legal acreage, the grower does not have
a legal supply of opium from which to withhold and divert to the
illegal market. It is as simple as that, Mr. Chairman.
It would be a definite plus, a definite step forward.
Thank you.

Chairman Pepper. Mr. Perito, will you inquire ?
Mr. Perito. Secretary Rossides, in 1969 the General Assembly of
Interpol took a position in reference to this. What was your position
at that time representing the U.S. Government ?

i\Ir. Rossides. We were for a complete ban on legal production of
opium worldwide.

Mr. Perito. Is that still the position of the U.S. Government ?
Mr. Rossides. Let me qualify that to this extent : Yes ; from the en-
forcement point of view we were stating that obviously and clearly it
would be of substantial help to the enforcement community — the var-
ious police forces, the various customs forces throughout the world —
if no legal production of opium poppy was allowed. That is still the
position of the Government.

That is not to say, though, that there may not be other factors in-
volved in the timing and phasing of this proposal. This is the push
that we would want. There would be no reason not to still have that
position.

Mr. Perito. There seems to me to be some reluctance expressed inso-
far as the codeine aspect of the ban was concerned. Do you have at
your disposal any more additional facts medically which would dis-
abuse some of the people who felt that we could not move on it insofar
as the synthetics for codeine were concerned ?

Mr. Rossides. Well, it would be the testimony— and this has to be
up to the medical profession— it Avould be the testimony that this
committee has heard today. I want to be very clear in the fact that as
a lawyer and as a person with responsibilities of enforcement at the
Department of the Treasury, and within the administration's enforce-
ment community, we do not try to intrude \ipon the medical judg-
ment. I recall, while working on the task force of Operation Inter-

cept, thereafter called Operation Cooperation, we pinned down
the doctors and said all right, what is the harm? Obviously, harm
you compare with the harm regarding heroin, because an estimated
15 percent of heroin is grown illegally and produced— from the
poppies — in Mexico and converted to morphine and heroin and smug-
gled in. But the other operation of Intercept was regarding mari-
huana.

What is the medical testimony? The medical evidence? We cross-
examined them and pushed them as this committee is pushing, and
rightly so, and they came back with the comment that there is no
known good for marihuana, it can lead to serious mental health prob-
lems, and taken in conjunction with other drugs it can have a more
serious effect. So we had to base it on the medical evidence and went
accordingly. Research since then has tended to confirm the problem
of marihuana.

Getting back to the specific point, that has to be up to the doctors,
but I concur, in listening to the testimony and the chairman's ques-
tions and Mr. Steiger's questions,; that the medical profession has
clearly ^ot to move ahead and rapidly. There is no simple answer to
the heroin problem. It requires a multidimensional approach.

I think the President has recognized this from the outset. This
committee has, and it is moving ahead on many fronts in education
and enforcement, for example. If I had a dollar to spend— well, I
would have spent, before these recent hearings, 90 percent on educa-
tion, maybe a little less on education, a little more on research, but
enforcement is just one of the elements in the effort.

I am convinced that the youth have acquired great concern about
heroin and some of the other dangerous drugs. They are not nearly
as convinced about marihuana yet, but every little bit helps and
every little bit of pressure helps, and particularly from the Congress.

Chairman Pepper. Mr. Secretarv, you heard the testimony of Dr.
Eddy, and I believe Dr. Brill. Both said that heroin addiction in this
country is growing. We have had testimony from the Bureau of
Customs and the Bureau of Narcotics and Dangerous Drugs that with
all of the splendid efforts they are putting forth and the millions of
dollars of money that Congress has made available to you, the
hundreds of new agents that you have been able to put on the job, yet
the problem is so colossal that you are able to seize only about 20
percent of the heroin coming into this country.

Now, here at home we have thousands of dedicated law enforce-
ment officers trying to stop the distribution of heroin in this country.
There is no foreseeable date, it seems to me, when by law enforcement
alone we are going to be able to stop heroin from getting into the
hands and the veins of the addicts of this country.

Do you generally agree to that ?

Mr. RossmES. The last statement I agree to — the last part of your
statement, Mr. Chairman — that law enforcement alone cannot do the
job. That is an absolute principle as far as I am concerned. I cannot
agree with certain of the other comments regarding statistics. No one
fully knows. Statistics in this crime area are not quite that reliable
because we don't have a scientific way of gathering them.

The heroin area and crime is one of the most unusual, because you
do not have a victim in the criminal sense as you do when there is a

bank robbery or an assault. You do not have the heroin addict coming
forward and complaining. He is trying to find where he can get
some more heroin.

I do feel the total effort which has been made in the last 2 years
has stemmed the tide. You can feel it when you are talking to some
of the college students and others. That doesn't mean we are still not
in a crisis situation.

Chairman Pepper. You mean, sir; we are not in a crisis situation
with respect to heroin use in this country ?

Mr. RossiDEs. I said that we are. We have done an enormous amount,
in my judgment, in the combined Federal and State establishment in
the last 2 years, and we have arrested a downward slide, in my own
personal judgment. I get this from many different people — from en-
forcement people, from students, and others.

But that doesn't mean we are not still in a crisis. We are; obviously
we are. But it took 10 years to get to this stage and the trip back may
take a long time.

Chairman Pepper. What we are trying to do is supplement the
splendid effort you law enforcement people are making by seeing if
it wouldn't be possible to stop the growing of opium. But you have
to stop the legitimate demand. In order to do that you have to have
effective substitutes,

Mr. RossiDES. From the enforcement point of view, this is essential.

Chairman Pepper. That is why I feel, and I hope this belief is
shared by the committee, that more money spent in research to find
these synthetic substitutes, and more money spent in trying to find
antagonistic drugs so that the pusher's market would be diminished,
would help law enforcement in the country.

Mr. RossiDES. No question whatsoever, Mr. Chairman.

I used to stress that out of the dollar I would want most of it going
for education. I have changed in the last year to now add the need
for research. I do want to point out the President has substantially
increased funds for research and education. But that doesn't mean more
may not be needed. That is up to the Congress and the executive to
work out.

Chairman Pepper. Mr. Blommer ?

Mr. Blommer. No ouestions, Mr. Chairman.

Chairman Pepper. Mr. Mann ?

Mr. Mann. Recognizing that the abolition of legal growing of the
opium poppy would necessarily be pursuant to an international agree-
ment, almost worldwide, what good would it do for the United States,
through the Congress, to take unilateral action to abolish the importa-
tion of opium ? What good would it then do you in trying to negotiate
an international agreement with other countries?

Mr. RossiDES. I would say, without commenting fully on the pre-
mise— because it can be done unilaterally by each country

Mr. Mann. Yes.

Mr. RossiDES. (continuing). The will of the Congress spoken after
hearings, after testimony, after review and analysis — that this is the
judgement of the Congress of the United States, would have, in my
judgment, a very salutary effect throughout the world, throughout the
nations that are members of the TTnited Nations, and it would be a
plus.

Mr. Manist. But without other sanctions we have merely cut off our
trading point as far as the control of the market is concerned if you
say, "Well, we don't need your poppy any more." Why should this
cause them to stop growing it ?

Mr. RossiDES. When you say sanctions, you are talking about nego-
tiation and added factors are involved ; this is another step in the ne-
gotiation process. I think, for the first time, the United Nations has
been galvanized to do something following the President's speech last
October, and our own contribution of $1 million out of a $2 million
pledge. I think other nations are coming forward. A conference on
the revisions of the 1961 Single Convention on the Control of Drugs
is planned, hopefully, for early next year with proposals for construc-
tive amendments bemg considered.

Now, all of this is helpful. I happen to feel that the publicity value
of public opinion, hearings, and of statements and of positions are
helpful. It is no panacea, but it is a step and it is a helpful step.

Mr. Mann. Thank you

No further questions.

Chairman Pepper. Mr. Wiggins ?

Mr. Wiggins. Yes, sir ; I would like to continue with the questions
started by my colleague, Mr. Mann.

The United States constitutes a major portion of the world demand
for the lawful manufacture of morphine, and accordingly, if we were
to stop our importation of it, it would have more than publicity impact
on those supplying countries ; wouldn't it ?

Mr. RossiDES. Yes, Mr. Wiggins ; I should have added that. It cer-
tainly would. The countries that are selling to us would not have the
market. So that they would then be possibly more inclined to look for
other crops.

Mr. Wiggins. We have observed in Turkey, for example, the elimi-
nation of provinces where the growing of poppy was permitted law-
fully. I think we are down to about six or seven now, as against a high
of more than 20 not too long ago.

Can you comment on the enforcement within the nation of Turkey
as to the illicit growing of poppy in those provinces where it has been
discontinued ?

Mr. RossiDES. Yes. Our reports are that it has been quite successful
in the provinces where it has been discontinued. It was up to 21 prov-
inces and is now down to seven. Reports that we receive are that in
those provinces in which growth has been lawfully discontinued, en-
forcement has been quite successful.

The. main growing areas are still in the seven provinces. But at least
the enforcement effort has been successful in the provinces.

I might conimend the Turkish Government for these efforts, and
they are devoting more manpower to this problem, and I might quote
the new Turkish Government's public comment recently made by the
Prime Minister, Mr. Erim :

Our Government believes that opium smuggling, which has become a terrible
disaster for the youth of the vporld, is hurting above all our humanistic senti-
ments : therefore due importance will be attached to this problem. Opium pro-
ducers will be provided with a better way to make a living.

That is a step forward. Everybody, including the United States,
has to do more, as this committee is pointing out.

Mr. Wiggins. Would the stopping of the importation of lawful
morphine into the United States, in your opinion, tend to stimulate
the Government of Turkey to accelerate its program of cutting down
these provinces where the opium poppy is lawfully grown ?

Mr. RossiDEs. I would have to pass on that. Congressman. I would
have to check with the State Department and get back to the commit-
tee. I just don't know. I am not m a position to know. (See exhibit 6.)

Mr. Wiggins. Well, let us suppose that there is no more lawful opium
poppy grown in Turkey. What impact would that have on organized
criminal activities in the United States ?

Mr. RossiDEs. Well, the impact would be significant, in my judg-
ment, and they would look to other sources, Southeast Asia, other
possibilities in the Near and Middle East. But clearly you have made
a major advance because you have disrupted a known pattern of
trade, of illegal activity.

One of the things that we are doing, we are making strenuous
efforts to analyze, review and do something about the situation in
Southeast Asia, even though the percentage, we estimate that the per-
centage of opium coming from there is quite small. There is an enor-
mous amount grown in Burma and Thailand, and most of it is used
in the area, but we are trying now for the first time to be ahead of
the game instead of our just reacting. In fact, the organized criminals
are not going to stop when they see a profit. We have to have a total
fight. It has to include enforcement, education, research; every possi-
ble way.

As I say, I think we have done a good job. I really do. But more

["» Q o "t c\ hf* ri on (^

Mr. Wiggins. It is generally known that the largest opium pro-
ducers in the world are India and the Soviet Union with Turkey
third. It is usually stated, however, that there is minimal diversion
from India and from the Soviet Union.

Do you think if we were to ban the lawful importation of morphine
that we run the risk of development of an illicit market in these two
areas ?

Mr. RossiDES. I do not.

Mr. Wiggins. Well, now let's turn to Mexico. Usually the figure is
5 to 15 percent, something of that range, is attributed to Mexico as a
source of heroin. It is not grown lawfully in Mexico at all. Mexico is
not one of the — what is it, seven — countries that may lawfully grow
poppies ?

Mr. RossiDES. Correct.

Mr. Wiggins. What impact do you think it would have, if any, in
Mexico ?

Mr. RossiDES. None — no real impact in Mexico — because it is already
illegal there as is the growing of hemp. The problem in IVIexico is that
the growth is in the mountains — very difficult areas to detect — and in-
accessible areas where it is quite difficult to prevent the growth. The
Mexican Government, however, has made many strenuous efforts and
has had some success. But a great deal more needs to be done and is
being done.

We have just concluded the fourth or fifth meeting with our col-
leagues from Mexico, and I commend the efforfs of the Mexican Gov-
ernment and the public condemnation by the Mexican Government of

the traffickin<2: in heroin and marihuana. They are doinji: better. Again,
it is an intei-national problem. We cannot be satisfied. We cannot say
that anyone is doing adequately, except maybe Japan, which took care
of the lieroin problem by tlie strictest kind of enforcement, moral and
cultural, and public effort. Every one of the policemen in Tokyo is a
narcotics expert, and with their tough customs efforts, Japan has done
the job. What I am saying is that I don't want to point a finger at any
one country, because we are all guilty. But no matter how much more
we are doing, we are not nearly at the point Avhere we can even think
of seeing the end of the road, and we are just going to have to redouble
our efforts.

Mr. WiGGixs. I would like to conclude, Mr. Chairman, with just a
brief comment.

I don't think any of us have ever felt that the prohibition against
the importation of morphine in this country would be in and of itself
a panacea. But there are many incidental fallout benefits for doing so.
One of them is the disruption of the organized criminal infrastructure
involved in the importation of heroin in this country. It took many,
many years to develop the chain from Turkey into the Port of New
York. That in and of itself is a substantial achievement.

Chairman Pepper. If you Avill excuse me just a minute, while you
are on that subject, there are two things I want to ask the Secretary.

One is, can you tell us what is the extent of the involvement as you
have found it of what we call organized crime in the importation of
heroin into the United States ? How deeply is organized crime involved
in the importation of heroin ?

Mr. RossroES. Mr. Chairman, practically every bit of heroin brought
into the United States is brought into the United States by organized
crime. The heroin traffic is a highly organized criminal conspiracy.

Now, what is the definition of organized crime ? That is where peo-
ple may disagree. My first law enforcement came while working under
Mr. Hogan, probably the greatest district attorney that the Nation has
had. He would never allow his assistants to use the word "Mafia," be-
cause it gave the false impression that the Mafia was the only part of
organized crime.

Organized crime is a criminal conspiracy of a continuing nature, I
would say this, that there have been more members of certain of the
IVIafia families involved before — probably less now — but the groups
that are involved now in the heroin traffic are of all ethnic groups, all
religious groups, and all racial groups. The key groups outside the
country are the French Corsicans. Certain of the families — the Mafia
families — are still involved at the importation level. They take their
cut on getting it in. They do not have, as they do in their other enter-
prises, the distribution system up and down the line. In gambling, for
instance, they will take care of someone that is pulled in, provide him
with counsel and take care of the family. That is not necessarily the
problem here.

You have a different distribution system. It is in the ghetto. The
blacks are profiting from it, the Puerto Ricans, ethnic, Irish, Italian,
Greek, every group.

My only point is that organized crime is involved, but we cloud the
issue when we try to equate organized crime with the Mafia.

My point is that organized crime is far broader.

Chairman Pepper. Can you give us an estimate as to the number of
people who make up that organized crime group responsible for the
importation of heroin into this country ?

Mr. EossroES. I would not have that at my fingertips, nor would we
have a firm figure of the number of persons involved.

Let me review that with my staff, Mr. Chairman, and try to supply
the committee with an estimate of the number of persons that you
are talking about.

Chairman Pepper. We would appreciate it if you would get us
that information.

The reason I ask particularly is because Mr. William Tendy, for-
merly of the U.S. attorney's office in Xew York, told our committee
that, as I recall it, 10 to 15 organized crime figures were responsible
for most of the heroin smuggled into the United States.

Mr. Rossides. I believe they meant syndicates. I would agree with
that figure. I would agree you are talking about probably up to 15
at a maximum of significant criminal conspiracies, of organized crime,
of all types, natures, and backgrounds.

Chairman Pepper. One other question. Do you have any estimate or
could you get us one as to how much all the growers of the opium
poppy in the world — I mean, growing it in any appreciable quantity —
are making from that production.

Mr. Rossides. I don't have it now. I will try and supply it, Mr.
Chairman.

(The information requested was not available at time of printing.)

Chairman Pepper. If we and others working with us were to give
every opium poppy grower in the world the same amount of income
that he is now deriving from the growth of the opium poppy, how much
would it cost the participating nations in such a program ?

Mr. Rossides. I will try and find out, Mr. Chairman, but I would
like to go on record as strongly opposed to any concept of preemptive
buying. It would simply stimulate production and it would take away
the responsiblity of each nation to handle the problem as part oP the
international community. I just want to make sure of that.

Chairman Pepper. I don't think anybody on this committee would
follow that will-o-the-wisp of wanting to start the United States in
buying all the opium production in the world. I am not talking about
that.

I am talking about if you got them to grow soybeans, wheat, or
something else, if they had the guarantee of the same income from the
growing of legitimate products, how much would the financial burden
be upon the nations including the nation where the growing occurs ?

Mr. Rossides. I would answer that. I will find out the figure, if it
is available. There would be no financial burden because what you
would be doing is substituting a crop. So really you would be making
an investment, a capital investment for the group.

Chairman Pepper. Yes.

(The information requested was not available at time of printing.)

Chairman Pepper. Mr. Steiger?

Mr. Steiger?

Mr. Steiger. I yield to Mr. Wiggins.

Mr. Wiggins. I have just one more question, Mr. Rossides. There is
the possibility that if effective synthetics are mandatory in this coun-
try that they in turn would be widely abused and diverted. Let's sup-
pose that happens. Has your experience indicated that the organized

criminal groups within this country have been in the business of di-
verting amphetamines, for example?

Mr. RossiDES. Oh, yes.

Mr. Wiggins. Do we change the nature of the enemy in any way ?
I would like you to comment on the ease or difficulty of controlling
diversion from lawful manufacturers in the United States as dis-
tinguished from lawful producers of natural poppy elsewhere.

Mr. RossiDES. I would refer the diversion problem to the Bureau of
Narcotics and Dangerous Drugs, which has the responsibility for pre-
venting illegal distribution of dangerous drugs. (See testimony of
John Ingersoll, Director, BNDD, on Jmie 2, 1971.)

There is no question that there are efforts by organized crime to
steal the pills, and one of the reasons for the Drug Abuse Act of 1970
was that before there were not the proper controls on the manufacture
and distribution in following production down the line so that you had
a controlled system. It was a simple thing to sell a million pills to a
post office box number in Tijuana and then smuggle them back into
the United States. It was really very simple.

My own feeling is if we are able to be more successful in stopping
heroin from coming in, organized crime would naturally try to divert
to dealing in pills. But again it is a manageable problem. It is some-
thing we are trying to do in the area of cargo theft. It is not that
difficult to develop a system at the ports of entry.

Mr. Wiggins. Is it more manageable than the difficulty you are
experiencing in preventing the importation of heroin ?

Mr. RossiDES. I haven't looked at it enough. In my judgment it
would be. But you have got to remember that a lot of pills are pro-
duced. I hadn't thought of the comparison of the problem, but it is
not — let me put it a different way. I would rather face the problem
of increased effort to divert the pills that would come from a sucess-
ful effort to prevent the heroin being smuggled into the United States,
I think that is far more manageable and we can move in that area by
careful controls by the manufacturers themselves in many ways.

Chairman Pepper. Mr. Steiger ?

Mr. Steiger. Yes, Mr. Chairman.

Mr. Secretary, you have been very candid, and I appreciate it. In
your relations with Interpol and with other enforcement people from
these other countries, as a cold, practical matter if there were to be —
somehow we could achieve international agreement that would ban
the poppy, how rigid do you think the internal enforcement would be,
say, in Turkey, and I might add that the seven privinces which now
produce, which Turkey has reduced the legality of the poppy, it is
my understanding and you indicated the same thing, that still had
about 90 percent of the existing poppy production. So it really sounds
good to go from 20 to seven, but we haven't reduced the production
by 30 percent.

In those areas of five or 10 poppy producers, as a practical, political
matter, how tough would their enforcement be ?

Mr. RossiDES. Well, even on the question — if it were made illegal ?

Mr. Steiger. Yes ; how tough would the Turkish police be on their
people ?

Mr. RossiDES. I think we have to commend the new Turkish Gov-
ernment for its forthright statement. The first time that a public
statement has been made, and I do commend them for that.

The problem then would be the will of the Government of Tur-
key, and I am convinced that they would be able to handle it.

Mr, Steiger. Well, of course, you know, we talk about preempted
buying. One area this country has expertise in is in paying people not
to grow things. We have a great, long history of that. I am con-
vinced, as apparently the chairman is, that we could produce a viable
plan in which we could augment the poppy growers' income to the
point where he wouldn't have to grow poppies at a fraction

Mr. KossiDES. Crop substitution is the answer. I don't consider that
to be preemptive buying.

Mr. Steiger. But we are dealing with a very real problem as we un-
derstand it, the guy wants to grow poppies, he has grown poppies
forever, and his folks before him, and that is something a little tough
for us to understand. I am asking you how valid is this desire to grow
poppies on the part of the seven Turkish provinces and how emo-
tional an issue is it within those provinces.

Mr. RossiDES. I would pass and let the State Department come up
with the analysis of the psychology of the Turkish farmer.

(The analysis referred to above follows :)

[Exhibit No. 6]

Department of State.
Washington, B.C., July 2, 1971.
Hon. Claude Peppeb,
Chairman, Select Committee on Crime,
House of Representatives.

Dexar Mr. Chairman : I refer to your letter of May 27, requesting informa-
tion about Turkey and opium.

As you may know, on June 30 that country's government showed a strong
sense of international responsibility in taking the diflBcult decision to ban further
opium cultivation to be effective approximately 1 year from now. Under Turkish
law farmers must be given 1 year's notice before opium poppy planting can
be prohibited in areas where cultivation has been permitted. Nonetheless, in
his statement explaining the opium ban, the Prime Minister has said that he
wU take every measure to eliminate smuggling and he will undertake a program
to induce farmers, who are legally permitted to plant in the fall of 1971. to
voluntarily abstain from planting. Beginning in the fall of 1972 opium poppy
will be banned throughout Turkey.

We have also been encouraged by other recent evidence of the Turkish
Government's intention to prevent Turkish opium from entering illicit channels.
On June 18, a strict opium licensing and control bill was reported out of com-
mittee; it was passed by the National Assembly of the Parliament on June 21.
The bill is now under consideration in the Turkish Senate. We anticipate that
the legislation will pass before the end of the session, now scheduled for July 30.

In addition, measures which the Turkish Government has taken to insure
collection of the total production from this year's harvest will result, we
believe, in a much improved performance. Among these new measures are :
training of additional agents ; an increase in the purchase price of the opiiuu
gum ; provision for advance cash payments to the farmers ; collection of the
gum at the farm immediately after harvest; and improved coordination of
tlie elements involved in the collection. Moreover, enforcement efforts arc also
showing improved results.

The amount of opiates seized during tlie first 4 montlis of 1971 (equivalent
to 574 pounds of pure heroin, which would have been worth about $00 million
in the IJ.S. market) is more than double that seized during the entire year of
1970. It is also more than the total amount seized by U.S. enforcement agencies
within the United States and at our borders during these same 4 months.

With regard to substitute crops, none have been identified tliat can replace
opmm pQppy in all the provinces where it is grown. Tlie Turkish Ministry of
Agriculture is conducting research into this problem witli assistance provided
under an AID loan. However, agricultural research by its very nature is a

slow prcx?ess. Some possible alternative crops have been identified and further
investigations are being conducted. The Turkish Agricultural Extension Service
is working with farmers in those areas where production has been banned teach-
ing the farmers ways of increasing their yields of such crops as sunflower seeds,
vetch, various fruits and vegetables and new varieties of wheat.

Prime Minister Erim recognized that the cost and diflBculties of controlling
opium cultivation were greater than the economic importance it has for the
Anatolian farmer, great as that is. His courageous and statemanlike action
will greatly help to reduce and to disrupt the existing pattern of illicit inter-
national traflBcking, and it will provide an example for other countries. I en-
close a translaton of Prime Minister Erim's statement explaining his Govern-
ment's reasons for terminating opium production and a copy of the Turkish
Government's decree.

I hope this information will be helpful. Please do not hesitate to call on us
when ever you feel we might be of assistance.
Sincerely yours,

David M. Abshire,
Assistant Secretary for
Congressional Relations.
(Enclosure 1)

Statement of Prime Minister Erim. — June 30, 1971

In recent years the abuse of narcotics in the world has assumed a very seri-
ous and dangerous condition. This situation has been described by the United
Nations as almost an "exp'osion." Several times more production is made of
narcotic drugs than is needed for legitimate and medical needs. For this reason,
the lives of millions of persons who use narcotics end. In some countries, this
deadly disaster is spreading rapidly, particularly among youth. It is noted that
even 12-year-old children are drawn to drugs. Countries which never used drugs
10 years ago are now its victim. The tragedy has spread even as far as the
African countries. Furthermore, addiction has begun to threaten all the mem-
bers of the community. Youth in particular must be protected from this addiction
as a great duty for the sake of mankind.

We have seen what a great danger the world is facing. We touched on this in
the Govenment program which our Parliament passed : "And indicated that
the problem of opium smuggling, which has become a destructive tragedy for
all young people in the world, will be seriously undertaken by the Government,
which believes before all else that this harms sentiments of humane considera-
tion. Opium growers will be given support by showing them a better field for
earning their living."

Indeed. Turkey has not remained a stranger to the development of the prob-
lem of narcotic drugs, to the international agreements made in this matter since
the beginning of the 20th century, and to the work of the United Nations. On
the contrary, she has joined in the agreements and has taken decisions to end
this disaster.

Turkey has participated in all the international agreements made on the sub-
ject of narcotics beginning with the Hague Agreement of 1912 ; those concluded
agreements in 1925, 1931, 1936, 1946. 1948, 1953 and 1961.

An important provision of the 1961 Narcotics Single Convention, signed by 78
nations, is the article which binds the production of opium to the permission
of the Government.

Governments coming before us have fulfilled their commitments to interna-
tional agreements and furnished all types of statistical information to the
authorized organs of the U.N. However, the need law establishing a licensing sys-
tem for planting in Turkey, which is the key point of this agreement, for some
reason was not passed until this year. Our state was continuously asked by inter-
nationally authorized organs to fulfill this commitment. This shortcoming was
criticized in the parliaments of many countries and by their public opinion. The
U.N. Secretary General in the report he presented on this subject in 1970, based
on these criticisms, said that an extensive amount of smuggling was being made
from Turkey.

After this, matters took a rapid turn. In the summer of last year the matter
was first taken up at the U.N. Economic and Social Committee. The Committee
on Narcotic Drugs was called to an extraordinary meeting. There, the critical
situation in the world was taken up and it was decided to start a struggle by

taking exceptional measures in the three stages of the problem : Production,
supply and demand, and smuggling. It was stipulated that a fund was to be
established to assure the financial means for this purpose. The subject was agreed
upon at the General Council meeting of the U.N. too.

In a law passed by the Turkish Grand National Assembly in 1966, Turkey
ratified the international agreement signed in 1961. In this way, international
commitments became a part of our national law. Accordingly, "In the event
one of the parties fails to implement the provisions of the agreement and through
this, the object of the agreement is seriously harmed, the control body will ask
that the situatiotrbe corrected and can go so far as to set up an embargo against
this country.

Smuggling made from our country in recent years has become very distressing
for us. Governments, whicli were unable to prevent smuggling, decreased the
number of provinces where poppies were planted from 1960 on and gradually
moved to the planting of opium from regions close to the border to the center
of Anatolia. Now planting has been decreased to four provinces. In this way it was
hoped to prevent smuggling.

However, imfortunately, this system did not give results. During 1970 many
things developed in favor of the smugglers. Although the soil products oflSce
obtained 116 tons of opium from the poppies planted in 11 provinces in 1969,
in 1970 the opium which reached the oflSce from nine pro\ances was only 60 tons.

The whole world is asking where the difference is going. The contraband opium
seized by our security forces, which we learn about in radio and newspaper
reports, shows everyone the extent of the problem.

It is certain that a smugglers' gang organized on an international scale, consti-
tutes a political and economic problem for Turkey. They will not be i^ermitted to
play around with the prestige of our country any further.

This horrible network of smugglers fools our villagers either with the wish
to make extra money or by force and it tries to use them for their own ends.
Of the tremendous sums which revolve around these transactions, the poor
hard-working Turkish villager actually does not get much. The smugglers pay
400 or 500 liras for an illegal kilo of opium to the villagers whom they force to
break the law. By the time this opium reaches Turkey's borders, the smugglers
have made a profit many times multiplied. After it leaves our country and
throughout its route, the value of the drug becomes augmented more and more ;
in the end it reaches an unbelievable price. International smugglers are earning
millions from the raw opium produced by the villagers, but the Turkish farmer
gets only a paltry sum. In countries where health is endangered through this
opium, because smuggling cannot be prevented in Turkey, anti-Turkish opinions
are created.

The Turkish villager also naturally feels bitter against this problem created
by the smugglers who make millions from the back of our farmers. All I'urkish
citizens also feel a moral pain that our country is blamed for smuggling which
is poisoning world youth.

The measures to be applied to control smuggling are extremely expensive. In
general, poppies are planted in one corner of the field. For this reason, it is
necessary to establish an organization which can control an area 10 times that
of a total poppy farming area of 13,000 donums which may actually be planted.
Vehicles, gasoline, personnel and their salaries must not be forgotten. Smugglers
on the other hand, it must be remembered, will resort to any means. Until now,
foreign assistance was obtained for control purposes; even an airplane was
obtained for our organization. But, unfortunately, the matter was imiK>ssible to
control by these means, in spite of all the efforts which were made. Our nation,
which is known for its honesty and integrity, is now under a grave accusation.
The time when we must end the placing of blame for deaths in other countries
on T'nri.-aT- is lori"' ovptIik^.

We cannot allow Turkey's supreme interests and the prestige of our nation
to be further shaken. Our government has decided to apply a clear and firm
solutioii. ii forbids completely the planting of poppies; they have already been
reduced to four provinces. The agreement ratified in 1966 also stipulates this
arrangement.

Poppies will not be planted in Turkey beginning next year. However, we have
given careful consideration to the fact that the farmers have until now obtained
a legitimate and additional source of income from the phinting of ix>ppies. For
this reason, in order that the poppy growers will not incur a loss in any way, the
necessary formula has been developed. This formula is: in order to make up

for the income farmers who are planting in provinces at present will lose, they
will be given compensation beginning from the coming year. This compensation
will work this way : the basis will be the value on the international market
of the whole produce, such as opium, seeds, stems, etc., that the planters will sell
to the soil products office this year.

Furthermore, in order to replace the income lost by farmers by other means,
and to provide them other means or earning a living, long-term investments will
be made in the region. Until these investments give fruit, villagers will continue
to be given comi>ensation. From among those who would normally plant this
year, those who voluntarily give up planting in the coming Autumn will be given
compensation on the same basis.

I am now addressing my villager citizens, in order that this plan may be
successful and that it will be possible to establish real values for future year
compensations and the criteria for investment, please turn over all your produce
to the Soil Products Office. You will receive the necessary assistance in this
respect We have also raised our purchasing price. The larger the amount turned
over to the office by all the poppy producers, the larger the compensation they
will receive in the coming years without planting. Bes(ide.s, by selling all his
produce to the TMO, the producer will prove he is not the tool of the smuggler,
that the Turkish farmer at no time had the object of poisoning the whole world,
nor that he encouraged this knowingly. Dear Farmer Citizens, you will be the
ones to save the prestige of our nation. The Government will also henceforth
give special importance to your problems. Our Government has taken precau-
tions in order that, in the end. not a siingle farmer family will incur a loss. Your
income will be met without allowing any room for doubts; at the same time,
it is planned to establish necessary installations to open new sources of income
in the region. I ask you to carry out this plan and to .sell all your opium products
for this year to the Office at the high price established last month, thereby you
will give this program a good start.

(Enclosure 2)

Turkish Opitjm Decree, June 30, 1971

On the basis of the letter of the Ministry of Agriculture dated June 26, 1971,
No. 02-16/1-01/342 ; per law 3491 as amended by law 7368, article 18 ; and per
article 22 of appendix agreement dated December 27, 1966, to law 812, the
Council of Ministers has decided on June 30, 1971 : Definitely to forbid the
planting and production of poppies within the borders of Turkey beginning
from the autimm of 1972. This Will be done by specifying the provinces shown
on the lists attached hereto.

1. To forbid poppy planting and opium producing in provinces where warning
is given as of the autumn of 1972 — Afyon, Burdur, Isparta, Kutahya.

2. To forbid popipy planting and opium producing in the provinces where a
warning has been g*iven from the autumn of 1971 — Denizli, Konya, Usak.

3. To give a suitable compensation as proposed by the Ministry of Agriculture
and by decision of the Council of Ministers to the planters in these seven prov-
inces where poppy planting and production have been forbidden. This Will be
on the basis of the opium they deliver this year to the Soil Products Office and
on the ba.sis of other poppy byproducts so that the farmers will not incur any
loss of income.

4. To grant to the planters in the areas indicated in paragraph 1, who volun-
tar'ily give up planting in the autumn of 1971, the right to benefit from the
compensation set forth in paragraph 3.

C. SUNAY,

President of the Republic.

Mr. RossiDES. But I only IPass in a sense. I don't want to duck any
question, because I keep coming back to what I think was a tremendous
statement by the new Government of Turkey, which I think they
should be commended for. The Prime Minister's statement, Mr. Erim's
statement, to the effect that the contraband trade in opium, which has
assumed the aspect of ovei- whelming blight for the youth of the whole
world, is offensive on humanitarian grounds. The Government will

60-206 O— 71— pt. 1 6

pay serious attention to this problem. Turkey's opium growers "will
be shown a way to earn a better living.

We should commend the Turkish Government for this statement.
I know what you are saying. The tradition of hundreds of years
and

Mr. SteiCxER. My only point in this whole line of questioning. Mr.
Secretary, and you obviously realize it, but I think it is important that
we understand it, as I think we do, is that it is obviously a positive
step, it is obviously appropriate, but we mustn't be deluded into think-
ing it is any kind of panacea and actually the difficulties that you are
now experiencing will not be alleviated completely. There will still be
attempts made by this organized crime organization if they have to go
somewhere else. It took them a long time to work up their Turkish-
American lines, but they now know how to do it and there are lots of
places they can go, as you indicated, and as Mr. Wiggins replied, there
is a question about Mexico.

I think it might be worthwhile if you could help the committee in
finding out what the Japanese customs did, for example, that enabled —
aside from the educational program they went through as described —
what actual

Mr. RossiDES. Correct. I will be happy to submit a statement that
the committee would hopefully consider whether it wanted to include
it as part of the record. I was not aware of the enormous success of the
Japanese until last year. It was a total effort by the Government and
was effective as a result of their cultural heritage, which provides
other avenues for relief of tensions. But their national police and their
customs police did a tremendous job, and they don't have a heroin
problem. In fact, they get upset when there is a seizure of marihuana,
as being a very dangerous thine, and thev are concerned about this
Nation's efforts to ease the penalties in marihuana.

We have a difficult problem. I think the easing of penalties was good
on the first offenders.

Chairman Pepper. Excuse me. You say you have that report?

Mr. RossroES. I will submit a statement regarding it.

Chairman Pepper. We will incorporate it with your testimony.

Mr. RossiDES. I will commend the Washinirton Post on this, because
it was their article last fall which was practically a full page article.

( The statement referred to above follows : )

Japanese Customs' Successful Curbing of Heroin Traffic

According to reports in the past few months, Japanese Customs have success-
fully curbed the importation of heroin into Japan. Much of this success was based
on tightened surveillance of incoming traffic — especially ships.

The customs officials were supported in their effort by strict enforcement of
narcotic laws by police who were well trained in narcotic enforcement, a hard
hitting press-TV campaign, and the cooperation of the Japanese people.

Chairman Pepper. Any other questions ?
Mr. Steiger. No.
Chairman Pkppfj?. Mr. Winn ?
Mr. Winn. Thank you, Mr. Chairman.

Mr. Secretary, two questions. Do you consider the college students
who bring heroin into the United States a part of organized crime ?

Mr. RossiDEs. I do not consider it a part of organized crime when a
college student goes overseas and purchases some heroin, or into Mexico
and brings it back and sells it to some of his fellow students. The
amount of this that goes on, in my judgment, is minimal, a very small
percentage. I don't even know if it is 1 percent. There are far more who
bring marihuana and hashish into the country, and they are quite
organized. In the New England area 600 pounds was seized. That
effort was highly organized and the marihuana and hashish were going
to be sold to fellow students.

Mr. Winn. My next question Avas what percentage and I think you
answered that. That may be 1 percent.

Mr. RossiDES. Yes ; a very small amount regarding heroin.

Mr. Winn. Do college students work with organized crime? They
may not be considered a part of it, but they are working with the
criminals to make

Mr. RossiDES. Sometimes, they are used as ducks or couriers. But do
not assume anyone who is bringing in heroin is an unsophisticated,
naive college student. I think very few are involved in heroin smug-
gling. Marihuana and hashish, moreso — and they are making a lot of
money on their fellow students.

Mr. Winn. Thank you.

Chairman Pepper. Mr. Keating ?

Mr. Keating. No questions.

Chairman Pepper. Any other questions ?

Mr. Mann ,• No ; thank you.

Chairman Pepper. Mi-. Secretary, we thank you very much for your
valuable contribution this morning.

We want to keep in touch with you and cooperate Avith you in any
way we can.
■ Mr. RossiDES. Thank you, Mr. Chairman.

Mr. Perito. Mr. Chairman, may the curriculum vitae of Secretary
Rossides be incorporated in the record.

Chairman Pepper. Without objection, it is so ordered.

(The curriculum vitae of Mr. Rossides follows:)

[Exhibit No. 7]

Curriculum Vitae of Eugene T. Rossides, Assistant Secretary of the
Trbiasury for Enforcement and Operations

As Assistant Secretary of the Treasury for Enforcement and Operations, Mr.
Rossides' responsibilities include direct supervision of the Bureau of Customs,
the U.S. Secret Service, the Bureau of the Mint, the Bureau of Engraving and
Printing, the Consolidated Federal Law Enforcement Training Center the Office
of Operations, the Office of Tariff and Trade Affairs, and the Office of Law
Enforcement.

Mr. Rossides serves as the principal law enforcement policy advisor to the
Secretary of the Treasury. His responsibilities include providing policy guid-
ance for all Treasury law^ enforcement activities, including those of the Internal
Revenue Service.

Mr. Rossides is responsible for the administration of the antidumping and
countervailing duty laws.

Mr^ Rossides serves as U.S. Repre.sentative to Interpol (International Crimi-
nal Police Organization) and was elected as one of three vice presidents of
Interpol in October 1969.

^ ^^,>'- I^ossides, 43, had been a partner in the law firm of Royalls, Koegel, Rogers
& ^\ells (now Royall, Koegel & Wells) of New York City and Washington, D.C.

From 1958 to 1961, he served as Assistant to Treasury Under Secretary Fred C.
Scribner, Jr., before returning to the practice of law in New York City.

Early in his law career, Mr. Rossides served as a criminal law investigator in
the rackets bureau on the staff of New York County District Attorney Frank S.
Hogan.

For 2 years, Mr. Rossides was an assistant attorney general for the State of
New York, having been appointed by the then Attorney General Jacob K. Javits,
who assigned him to the bureau of securities to investigate and prosecute stock
frauds.

A former legal officer for the Air Materiel Command, U.S. Air Force, Mr. Ros-
sides holds the reserve rank of Air Force captain.

A native of New York, Mr. Rossides graduated from Erasmus Hall High School,
Brooklyn, and received hi'* A.B. decree from Columbia College in 1949. He re-
ceived his LL.B. degree from Columbia Law School in 1952. He is a member of
the Columbia Co lere Coun'^-il, n director of the Co umt>ia College Alumni Associ-
ation, and a member of the Columbia College Varsity "C" football club.

A member of the Greek Orthodox Church, he serves on the church's highest rul-
ing body, the Archdiocesan Council of the Greek Orthodox Church of North and
South America, both as treasurer and member of the coimcil's policy committee.

He is a vice president of the New York Metropolitan Chapter of the National
Football Foundation and Hall of Fame, and a director of the Touchdown Club
of New York.

He is a member of the American, Federal, and New York State bar associations,
and New York State District Attorneys Association, the American Political Sci-
ence Association, and the Academy of Political Science.

He is married to the former Aphrouite Macotsin of Washington, D.C. They
have three children Michael Telemachus. 8; Alexander Demetrius, 6; and Eleni
Ariadne, 3. Mr. Ros.sides has another daughter. Gale Daphne, by a previous
marriage.

Chairman Pepper. I would just like to announce before we break
up that these are the witnesses for tomorrow: the MITRE Corp.
representatives: Mr. David Jaffe, department staff; William E.
Holden, department head, resources planning department; Dr. Walter
F. Yondorf , associate technical director.

Then next is Dr. Frances R. Gearing, associate professor, Division of
Epidemiology, Columbia University School of Public Health and Ad-
ministrative Medicine.

Next is Dr. Jerome H. Jaffe, director, Illinois Drug Abuse Program ;
Wayne Kerstetter, University of Chicago Law School Research Center.

Next is Dr. Robert L. DuPont, director, Narcotics Treatment Ad-
ministration for the District of Columbia.

If there is nothing further, we will recess until 10 o'clock tomorrow
morning in this room.

Thank you.

(Whereupon, at 1 :1T p.m., the committee adjourned, to reconvene
on Tuesday, April 27, 1971, at 10 a.m.)

NARCOTICS RESEARCH, REHABILITATION,
AND TREATMENT

TUESDAY, APRIL 27, 1971

House or Representatives,
Select Committee on Crime,

Washington^ D.C.

The committee met, pursuant to notice, at 10 :05 a.m., in room 2359,
Rayburn House Office Building, Hon. Claude Pepper (chairman)
presiding.

Present: Representatives Pepper, Eangel, Mann, Brasco, Waldie,
Wiggins, Steiger, Winn, and Keating.

Also pr(;sent : Paul Perito, chief counsel ; and Michael W. Blommer,
associate chief counsel.

Chairman Pepper. The committee will come to order, please. We are
very pleased to see in the audience this morning a large niunber of
young ladies and gentlemen. We hope you will find something of
interest in the hearings we are holding today.

Yesterday, the Crime Committee heard testimony from three
uniquely qualified and eminently distinguished scientists and medical
researchers. Doctors Seevers, Eddy, and Brill all agreed that we now
have sufficient synthetic substitutes for morphine and codeine ca-
pable of satisfying the painkilling and cough suppressing needs of our
Nation.

For those who were not here yesterday, let me say that the Select
Committee on Crime is trying to find some way to diminish the menace
of heroin addiction in this country. We have already heard evidence to
show that in spite of all the efforts of the Federal Government and
all those agencies cooperating with the Federal Government, we seize
only about 20 percent of the heroin that is smuggled into this country.
The other 80 percent comes into this country to be the largest single
cause of death of young adults in some of our largest cities.

Last year, in Dade County, Fla., my congressional district, we had
41 deaths from heroin. We have already had nine this year. The num-
ber is in the several hundreds in the United States each year.

So in view of the difficulty of stopping heroin from coming in, we
are looking at some options, or some alternatives, as it were. If we
could just stop the worldwide cultivation of the opium poppy alto-
gether, that would, of course, eliminate that problem. It would make
it unnecessary to spend so much money trying to intercept the opium
smuggled into this country in the form of heroin.

But in order to do that, we have to eliminate a very large legitimate
need for derivatives of opium, because doctors use morphine and co-

(77)

deine in painkilling drugs. So if we cannot eliminate that legitimate
need for the growing of the opium poppy, it will continue to be grown
and the farmer, at least according to the pattern of the past, will con-
tinue to divert a part of his crop into the black market maintained by
the international organized crime syndicate.

In order to eliminate the necessity for importing certain derivatives
of opium for medicinal purposes, we are asking the scientific com-
munity of our country if there caimot be developed synthetic substi-
tutes for morphine and codeine so there wouldn't be a legitimate need
for the growing of the opium poppy anywhere in the world.

The other aspect of this hearing is to find blockage drugs which
will prevent the addict taking heroin from experiencing any sensa-
tion from it. So if you take that blockage drug, you might as well not
take the heroin, because you don't derive any sense of satisfaction from
the taking of it. That is the reason we are engaged in this scientific
inquiry into these areas.

We have received testimony from Assistant Secretary of the Treas-
ury Eugene T. Rossides, who told us that the total eradication of opium
cultivation, accompanied by domestic reliance upon synthetic sub-
stitutes, would be a definite plus to the law enforcement community
charged with the responsibility of policing our borders. Mr. Rossides
further told us that the switch from the natural opiates to the syn-
thetics might well cause a disruption in the organized criminal con-
spiracies which are responsible for bringing most of the heroin into
the United States.

Today, we will hear testimony from scientific researchers concern-
ing the possibilities of policing a worldwide opium cultivation ban.
The first three witnesses, from MITRE Corp., will tell us about the
possibility of using our satellite capabilities to police an international
treaty banning opium cultivation. We will also hear testmony about
the role which the scientific and engineering community can play in
the international addiction crisis.

We then will move into the second phase of our hearing. In this
segment we will attempt to determine whether methadone mainte-
nance is efficacious in reducing the number of arrests and illegal activ-
ities of addicts under such treatment.

It is generally said that it costs between $50 and $75 a day to main-
tain heroin addiction once a person becomes thoroughly addicted to
that drug. Well, not many people can afford $50 or $75 a day. Those
who cannot afford it have to go out and illegally get possession of
goods, which, when sold to a fence, will yield the amount of money
they must have to sustain their addiction.

It is estimated bv Dr. DuPont, who is in charge of the Narcotics
Treatment Administration here in the District of Columbia, that
each addict in the District of Columbia gets illegal possession of about
$50,000 worth of goods a year in order to sustain his addiction. With
some 16,000 addicts in the District, it is no wonder we have so many
robbery, burglaries, and muggings on the street.

Our next witness. Dr. Frances R. Gearing, is eminently qualified to
give us an analytical and statistical survey of Dr. Vincent Dole's meth-
adone maintenance program that will help us in determining the ef-
ficacv of the methadone maintenance approach.

We then will hear from Dr. Robert L. DuPont, Director of the Nar-
cotics Treatment Administi-ation, who has compiled some fascinating
statistical studies on crime reduction and methadone maintenance in
Washington,

Our final witness today is Dr. Jerome H. Jaffe, director of the Illi-
nois Drug Abuse Program. This multimodality treatment program is
the largest in the Midwest. Currently Dr. Jaffe and his able staff are
treating 1,590 addicts. Dr. Jaffe will explain his approach to metha-
done maintenance and the multimodality treatment method. He will
also share with us his thinking about the possibilities of developing
longer lasting and effective antagonist drugs. Finally, Dr. Jaffe will
advise us how we can best accelerate and coordinate scientific research
into the multiple problems of opiate addiction.

Our first witnesses this morning are three gentlemen who represent
what America's advanced technology can contribute to the fight against
social ills. David Jaffe, William E. Holden, and Dr. Walter F. Yon-
dorf are employees of the MITRE Corp., a research and development
think-tank with heavy experience in space and defense.

These gentlemen are now applying their technology to the possibil-
ity of detecting the illegal cultivation of opium.

Mr. Jaffe is a memlier of the department staff of MITRE, and is
primarily concerned with the application of technology to criminal
justice systems.

Before joining MITRE last September, he was deputy head of the
public safety department of the Research Analysis Corlp., where he de-
veloped program concepts for research in law enforcement and the
administration of justice. Studies he directed included the relationship
between the physical environment and the crime rate, logistic support
to police and fire departments in combating civil disorders, and the role
of police in a ghetto community.

Mr. Jaffe holds a master of science degree in physics and mathemat-
ics from the University of Connecticut.

Mr. Holden, a MITRE department head, is an electrical engineer
with a bachelor of science degree from the Massachusetts Institute of
Technology, and a former naval aviator. During the last 15 years at
Lincoln Laiboratory, MIT, and with MITRE, Mr. Holden has been
responsible for many mission analyses and other planning activities
in the fields of air defense, command and control at senior military
levels, foreign satellite identification, airborne command posts, air-
borne launch facilities, missile test ranges, and Air Force test centers.
He served as a foreign service officer assigned to the NATO interna-
tional staff for 2 years to assist in planning NATO-wide air defenses.

Dr. Yondorf is associate technical director of MITRE Corp's na-
tional command and control division in McLean, Va. The division
provides systems engineering and other scientific and technical assist-
ance to defense agencies, primarily in the areas of communications,
data processing, and sensor development. Sponsors include the De-
fense Communications Agency, the Defense Special Projects Group,
Safeguard Systems Command, Air Force Systems Command and the
Advance Research Project Agency. Dr. Yondorf's earlier MITRE as-
signments have included the development and implementation of a
5-year project to improve and automate JCS strategic mobility plan-

ning capabilities, responsibility for requirements analysis of the Na-
tional Military Command System, the study of attack assessment sys-
tems, and research in crisis management.

Before joining MITRE in 1962, Dr. Yondorf was a senior staff mem-
ber at the Laboratories for Applied Sciences, University of Chicago,
where he was engaged in strategic studies and the political and eco-
nomic analysis of limited conflict. Earlier, he was an instructor at
the University of Chicago teaching courses in the committee on com-
munication.

As a fellow of the Social Science Research Council, 1959-60, Dr.
Yondorf undertook a study of the dynamics of political and economic
integration in the European Common Market.

Dr. Yondorf was educated in Germany, Switzerland, and the United
States, and holds M.A. and Ph. D. degrees in political science from the
University of Chicago.

Gentlemen, we are pleased to have you with us today.

Mr. Perito, our chief counsel, will you please inquire of the witness.

Mr. Perito. Mr. Jaffe, I understand that you have a prepared
statement ?

STATEMENT OF DAVID JAFFE, DEPARTMENT STAFF, MITRE CORP. ;
ACCOMPANIED BY : WILLIAM HOLDEN, DEPARTMENT HEAD; AND
DR. WALTER YONDORF, ASSOCIATE TECHNICAL DIRECTOR,
NATIONAL COMMAND AND CONTROL DIVISION

Mr. Jaffe. Yes ; I do.

Mr. Perito. Would you care to read that statement for the
committee ?

Mr. Jaffe. Yes.

Mr. Perito. Thank you, please proceed.

Mr. Jaffe. Thank you very much. I am pleased to contribute to
the work of this committee at your kind invitation, and am grateful
for the opportunity to discuss with you the role that the technical
community should be playing in the control of narcotic and dangerous
drugs. I will suggest how the application of technology could make
some significant contribution to the solution of the pressing and criti-
cal problems of drug abuse and to the control thereof : I will describe
some typical benefits that may be derived from the adaptation of ad-
vanced techniques; and I will suggest a program for realizing such
benefits.

A little less than a year ago this committee heard a presentation by
Dr. William F. Ulrich of Beckman Instruments in which he outlined
the ways in which scientific and engineering capabilities could con-
tribute to drug control. He touched on the subjects of technology
transfer and systems analysis, and I would like to expand on those
topics to show how some specific programs might assist those conduct-
ing the fight against illicit drug production and distribution.

Suggestions on how to solve the drug problem differ as to approach.
There are those who argue for an attack on the sources: Foreign
growers of opium and local manufacturers of psychotropic substances.

There are others who would have us concentrate on interrupting the
distribution channels. Still others believe the attack should be focused
on rehabilitating the users. I submit that we need a coordinated effort
in all these directions.

To say that the problem is complex is not to argue that solutions are
impossible, or slow to be realized. My thesis is rather that, if we are
to achieve effective controls in reasonable time, we must begin by
accepting the complexity, understanding it fully, and devising rea-
soned rather than intuitive or emotional responses.

Techniques which were developed for analysis of highly complex
systems, if properly understood and managed, can be powerful weap-
ons in revealing subtle relationships and vulnerabilities. The methods
of systems analysis and systems engineering are not cure-alls. As
with any highly structured method, the results cannot be more precise
than the information used.

BACKGROUND

What then are the particular problems which should be addressed
by the scientific and engineering community ?

Source Detection

The sources of opium, the fields of the Middle East, Southern Asia,
and of Southeast Asia, present an interesting challenge because of the
combination of difficulties encountered. To begin with there is the
problem of detecting the presence of small, out-of-the-way, illicit
crops, primarily an operational and technological problem. Then there
is the consideration that opium is often the principal or only cash
crop for the local farmer, an economic problem. In Southeast Asia,
some tribes have built a nomadic lifestyle based on opium poppy culti-
vation, a sociological problem. And we hear frequently about the polit-
ical barriers to opium control.

The necessity to solve each kind of problem, and all of them on an
integrated basis, is apparent. The detection of illicit crops is a key
factor in the entire process because it should provide the detailed
facts on which can be based the economic, social, and political solu-
tions. Other parts of an integrated program rely, to some degree, on
being able to specify the location and extent of illicit opium cultiva-
tion with precision and confidence.

Laboratory Detection

A second major problem area which may be amenable to techno-
logical attack is the location of the laboratories where the opium and
morphine bases are transformed into heroin.

In the past, these laboratories have escaped detection from the air.
They remain prime targets partly because of their strategic function
in the heroin supply process, and partly because much raw material
and important personnel can be captured at these places.

Tracers

It would be helpful to law enforcement officers if they could reliably
trace the movement and chemical transformation of narcotic ma-

terials. If they could introduce an identifiable tag at the poppyfield
and intercept some of that material at several points in the distribu-
tion network, a much clearer description of that network would result.
The operational possibilities for such tracer materials are numerous.
The problem is in finding suitable tags which are, among other things,
reliable and safe.

Sensors

Another problem susceptible to technological solution is the detec-
tion of concealed drugs at short distances. It would be of immeasur-
able value to be able to reveal the presence of drugs hidden in suit-
cases, automobiles, packages, on the person, and in many other places.
Devices are needed which can detect extremely small amounts of opi-
ates w^ith response times of seconds and reliability in the upper 90
percentile. The requirements of sensitivity, speed, and reliability tend
to be mutually exclusive and difficult to achieve. Development of such
devices requires extensive research and design and some amount of
tradeoffs in design.

Data Bank

The complexity of the international drug enterprise is reflected in
the great amount of information needed to describe the production,
distribution, and consumption of the products. The effectiveness of
drug control is dependent on access to that information. And the ef-
fectiveness will also be a function of how timely the retrieval is and of
how complete is the data produced.

It follows that a comprehensive data bank is required as a reposi-
tory of worldwide information on all aspects of the drug problem.
Narcotics agents at all levels should be able to request rapid retrieval
of information. The high mobility of dealers in drugs and the world-
wide nature of their operations suggest the need for a similarly ex-
tensive data bank.

O'perations Analysis

Referring again to the intricate nature of the illicit drug business,
it is often difficult to predict the ultimate consequences of any control
activity. Squeezing the balloon at one place may simply cause it to
expand some place else. A comprehensive, systematic, analytic method
is needed which can help to identify how other parts of the system
will be affected if one part is changed.

A corollary problem is the allocation of drug control resources.
Like managers in all other situations, drug control administrators
must decide how to assign their personnel, equipment, dollars, and
management attention so as to realize the most beneficial results. It
would help these people to have a technique for anticipating the
effects of their allocation decisions. No such technique will replace a
good manager, but it can provide him with information he would
otherwise not have.

BENEFITS

Some of the benefits which should be derived from such efforts
by the scientific and engineering community are :
Worldwide location of opium crops ;
Information on potential yield of opium crops ;

Determination of harvesting time ;

Selective destruction of crops ;

Tracing of distribution networks ;

Sensing of concealed material at ports of entry ;

Detection of clandestine laboratories ;

Kapid retrieval of pertinent data ;

Identification of network sensitivities and vulnerabilities ;

Assessment of alternative control measures :

Mechanism for training exercises ; and

Good resource management.

I must urge you to keep in mind that these benefits, as I have been
calling them, are not going to solve the full range of narcotic and
drug problems. In fact, we cannot be entirely certain that all of these
benefits, and others which could be added to the list, can be achieved
in a reasonable time or at acceptable costs. And the changing opera-
tional requirements may make some of them obsolete before long.

But for the present, we should not overlook any tool which answers
a real need, and these benefits can be vital elements to the integrated,
coordinated attack which, in my opinion, is the only reasonable route
to effective control.

PROPOSED PROGRAM

Before identifying how the scientific and engineering community
might participate in the control of drugs, I wish to acknowledge that
there are already in progress some efforts along the lines to be de-
scribed. The Bureau of Narcotics and Dangerous Drugs and the Bu-
reau of Customs have active research and development programs which
address many of the points contained in this statement. In addition
to their own projects, these Bureaus are being assisted by other Fed-
eral agencies which have specialized capabilities. I have met with a
number of people involved in these efforts and can attest to their
competence and dedication. But the scope of the ongoing efforts, and
the adequacy of available resources, remain as appropriate questions
before this committee. I will return to this issue presently.

Having established some of the benefits which research and develop-
ment should pi'oduce, let us examine how such a program might be
structured. We can conveniently view the woi'k that needs to be done
as a five-part program.

Surveillance of Opiy/m Poppy Crops

The remote sensing — that is, from aircraft and satellites — of agri-
cultural crops dates from the early 1930's when aerial photographs
were used to locate and measure fields. Since then, observational and
interpretive techniques have progressed a great deal, although much
experimentation and development remains to be accomplished. I have
several photographs to illustrate what can be accomplished with ad-
vanced techniques.

Mr. Perito. Mr. Chairman, may the record reflect the lights are noAv
being turned out and the photographs about to be shown will be made
available for the committee to incorporate in its record.

Chairman Pepper. So ordered.

Mr. Jafte. The first figure is a well-known photo made from Apollo
9 at 131 nautical miles over Imperial Valley, Calif. It was taken with

Figure 1

infrared Ektachrome film with a spectral response between 0.510 and
0.890 microns. The dark dotted patches are crops. Across the bottom is
seen a section in which the amount of dotted area, and consequently the
vigor of the vegetation, is markedly lower. That sharp line of demarka-
tion is close to the Mexican border. A single color photograph like this
one contains limited useful information.

The next figure (fig. 2) shows the same scene in three photos made at
the same time. The one on the upi^er left was taken with Pan X film
with a green filter; the upjx^r right on Pan X with a red filter; and the
lower photo on black and white film "sensitive to infrared radiation. It
is apparent that each photo produces different relative contrasts and
enhances the images of some features over others.

The next photos (fig. 3) demonstrate the different resi^nses that
similar crops will provide in relatively narrow spectral bands. The left
photo, made with a blue filter, shows little difference between oats and

Figure 2

wheat. But the ones made with red and infrared filters show the dis-
tinction quite clearly. So, in a simple case at least, we see that it is
ix)ssible to isolate crops in this way.

In fact, it is possible to do a lot better than that. The next photos
(fig. 4) show how two varieties of corn which can hardly be differenti-
ated at visible wavelengths (on the left) look quite different at infrared
wavelengths.

Mr. Perito. May the record reflect the lights being turned back on
and we are continuing with Mr. Jaffe's statement.

Chairman Peppek. Without objection, so ordered.

You may proceed.

Mr. Jaffe. What I have illustrated here are the mere fundamentals
of remote sensing of agriculture. These techniques have been advanced

Figure 3. — Tones of wheat (W) and oats (O) differ when recorded by an airborne
multilens camera filtered to three spectral regions (0.38 to 0.44 micron, at left ;
0.62 to 0.68, center; and 0.58 to 0.89, at right).

[Data Collected by Purdue University Agronomy Farm.]

to include simultaneous observation in many spectral bands and com-
puter analysis of the data.

I am not aware of opium poppies having been observed by these
methods, but it is reasonable to expect that they would be readily dis-
cernible; perhaps even by single band, rather than multispectral, sens-
ing. "VVliat is needed is a set of experiments to establish which ap-
proach produces the desired information with reference to opium
poppy cultivation. It should be possible to use either an established
poppyfield or a specially prepared one and to overfly it with equip-
ment designed for spectral analysis. The signatures of poppies could
thus be obtained and examined for uniqueness. Once unique, charac-
teristic images are obtained from the test bed, the appropriate appa-
ratus would be used in an operational test to determine what, if any,
real-life difficulties might be encountered. Further refinement of the
technique would follow.

Remote sensing from aircraft is very likely to be successful in locat-
ing opium fields. Similar observations from satellites, particularly
from NASA's Earth Resources Technology Satellite (ERTS), are
somewhat less certain to produce useful results. The multispectral
sensing devices on the initial ERTS spacecraft will provide resolution
of objects down to about 300 or 400 feet. The smallest opium fields
are said to be about i/^ acre or typically about 150 feet in linear di-
mension. It is possible, but not at all certain, that a distinctive signa-
ture of that size will be discernible by an instrument with the resolu-
tion available on ERTS. Needed is experimental determination of the
poppy signatures and some experience with the real capabilities of the
ERTS instruments. We must also consider future instruments that
may provide finer resolution and other favorable characteristics.

Trace?' Technology

Tracers, or tag identifiers, can be used to identify captured samples
as coming from the same sources. It may be possible to introduce trac-

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ers at the poppyfields or at any point thereafter. For manufactured
drugs, methods of tracing are not nearly as difficult because of distinc-
tive characteristics of tablets and capsules.

Four primary handicaps exist in the use of trace materials ; insert-
ing the tracers into the drugs and the tagged drugs into the illicit
traffic ; the tracer must be safe for use internally or intravenously ; the
tracer must be highly reliable ; and a tracer, to remain a unique identi-
fier, cannot be reused until the tagged material has been cleared from
the marketplace — a condition which can require several years.

The advantages to be derived from being able to correlate the origin
of captured samples, and therefore being able to correlate the network
links and nodes, should compensate for the difficulties involved in over-
coming the handicaps. Captured shipments can be tagged and rein-
serted in the network ; radioactive tracers may not be totally safe, but
chemically idenifiable tag materials are possible; the reliability of
unique identification can be very high; and large numbers of trace
materials can be found in time. To introduce tracer materials into the
poppy plant, and consequently into the opium, requires trace materials
that can survive the processing that transform the opium into heroin.
Analysis of the morphine alkaloid, the heroin, and the impurities that
remain after processing could suggest ways of altering the chemical
composition. Alterations would presumably be distinguishable and
hence would serve to identify a particular batch of material.

Trace materials can also be inserted into the distribution network
at points other than the source. For this purpose, it is necessary to
have tag materials which replace those used at later stages in the proc-
ess. For example, it could be possible to use traceable acetic anhydride
in converting morphine base into heroin (diacetylmorphine).

It should also be feasible to introduce trace materials still later in
the network ; as for example, during the cutting phases. Either chem-
ically distinguishable but similar substances could be used, or inert
and distinctive things, perhaps plastics, could be added. But all of this
will take intensive investigation and development before operational
utility is achieved.

Sensor Technology

Sensors for the detection of concealed narcotics and drugs, and for
the detection of effluents at heroin laboratories, will also require dedi-
cated research and development. The first task will be to identify
technioues which can sense very small amounts of drugs or related
materials. The second task will be the adaptation of those techniqu'°s
to operationally useful forms.

More so than for other technological weapons, sensors are highly
susceptable to countermeasures. It should be fairly easy, once the sens-
ing technique is recognized, for the narcotic distributors to devise eva-
sive procedures or devices. The need is therefore for an arsenal of sen-
sors and a variety of ways for utilizing them in order to keep the other
side off balance.

There are a number of analytic technioues which are useful in
identifying narcotic and dangerous drugs. These methods include gas
chromatography, infrared spectroscopy, mass spectroscopy. X-ray
spectroscopy, free radical electron resonance, and a number of chemi-
cal analyses. But the apparatus which is most attractive for the opera-

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tional situations has handicaps. These devices require preconcentration
of the sample material, are too heavy to be portable, or may react too
slowly for expedient analysis.

However, mass spectrometers have been made with reduced size and
weight, and trade-offs are possible in design requirements. The recent
intensive effort in developing air pollution monitoring equipment has
resulted in promising devices and technology which might be applied
to the near real-time detection of gas or particulate contaminants as-
sociated with the production of controlled drugs. ^lerging the fields
of qualitative instrumental analysis with particulate detection, the
possibility arises of highly special and sensitive mechanical sensors.
Dr. Lou Rabben of the MITRE Corp. suggested a scheme developed
for another purpose. He proposes to use an infrared spectrometer with
a sample chamber constructed in such a manner that the infrared beam
passes through the gas sample many more times than is usually the
case for this type of analysis. Hopefully, this would result in greatly
enhanced sensitivity. I must emphasize that the applicability of this
or other techniques to drug detection is unknown. I merely wish to
suggest examples of how the application of sensor technology might
be pursued in the solution of these problems. Similar developments
may be possible with other techniques. Adaptation of existing tech-
nology would seem to be a sensible approach to the initial acquisition
of suitable equipment.

Data handling

I spoke isarlier of the need for a comprehensive data bank covering
all facets of the drug enterprise. A data bank will serve both the re-
search community in its efforts to analyze the system and find its weak-
nesses, and the enforcement agencies in their operational activities. I
doubt the need to elaborate on this item except to mention that a modest
start has been made in this direction.

Network modeling

The established technique of network modeling could be applied to
describe the entire procedure whereby narcotic and dangerous drugs
proceed from source to user. Such a model would include :

(1) Location of illicit poppy fields; (2) growing seasons of illicit
poppyfields; (3) economic analysis of poppy cultivation ; (4) packag-
ing and transport of raw opium; (5) ports of exit and entry, plus
procedures followed to avoid detection; (6) chemical processing:
(a) plant locations,
( h ) methods of shipment to and from,

[d) chemical and supplies used ; where obtained ;

(7) finished product handling and shipping; (8) distribution
systems :

{a) economic analysis,

(6) organizational structure; and

(9) covert intelligence ; its cost versus its value.

At each point of the network, alternative routings, sources or pro-
cedures should be identified to reveal how the network Avould be dis-
rupted by elimination or modification of that point.

The economic as well as physical networks should be simulated and
these models should be operated to determine alternative control meas-

ures; to assess likelihoods of success of those control measures; to
evaluate sensitivities of the systems to variations of the elements; and
to identify the links and modes which may be most susceptible to at-
tack. A corollary use of the models should be the training of super-
visory level personnel in the Federal and local enforcement agencies.

APPROACH

A few words on how to proceed with a research and development
program.

The various aspects of applicable technology- — surveillance, trac-
ers, sensors, a data bank, and network modeling — must be structured
into an integrated and focused research and development program.
In a systems approach of this kind, the benefits are not only those re-
sulting from each specialized technique or procedure, but also from
the coordinated use of all methods available.

As mentioned earlier, there is some work underway in the areas
cited, so any program should begin by assessing the scope and direc-
tion of those efforts, I have made a limited survey which indicated that
current efforts are minimal.

In addition to a status survey, an intensive feasibility analysis
should be undertaken to reveal what may be technologically, eco-
nomically, and operationally possible both in the short term and the
far term. This feasibility study would, using a complete systems ap-
proach, show just which of the areas I have mentioned are most fruit-
ful to pursue at the present time. The efforts in this area which are
underway at BNDI) and the Bureau of Customs, and through them by
other agencies, need to be enlarged and unified by this coordinated
across-the-board attack on the drug problem. Important consideration
should be the operational needs — the real-life situations faced by en-
forcement agents — and potential countermeasures.

The feasibility analysis should be followed by a detailed research
and development plan providing for the elements of the program sug-
gested above and including cost estimates and multiyear projections.
The plan must be produced from the point of view of an attack on the
entire drug problem ; from the producers to the chemical processors
to the street level distributors and users. The drug problem is not
static; the planning and implementation of its control cannot be static
either. Every plan must be part of a logical long-term effort, but the
plan will change as the problem changes. The plan should include
provision for evaluation of results achieved and for readjustments in
scope and direction.

SUMMARY

I have tried to indicate some of the problems faced by drug con-
trol agencies, to show what benefits could be derived from increased
employment of technology, and to indicate an approach to increased
involvement by the research and development community.

Programs of the kind suggested are not inexpensive and often re-
quire more time than one would like. But in the context of the overall
drug problem and its direct and indirect social and economic drain
on our society, the costs of an intense research and development pro-
gram would be small indeed in view of the potential benefits, such
as —

Locating illicit opium crops ;
Detecting illegal material at ports of entry ;
Developing drug network vulnerability data ; and
Improving resource management.

The important aspects are (1) the need for a total systems ap-
proach; (2) the need for an accelerated research and development
effort ; and (3) the need to get started now.

Thank you very much.

Chairman Pepper. Mr. Jaffe, I want to commend you on your mag-
nificent and comprehensive statement, that you have given as to how
this whole problem should be coordinated in an effective and compre-
hensive program.

Mr. Perito, do you have any questions ?

Mr. Perito. Mr. Jaffe, you have had some contact both with the
Federal Bureau of Narcotics and Dangerous Drugs, and U.S. Customs
regarding your presentation ; is that correct ?

Mr. Jafft:. Yes.

Mr. Pertto. Could you estimate what it would cost the Government
at this point to put together the type of research and development
program which you have suggested ?

Mr. Jaffe. It is very difficult to answer that on a short-term basis.
On a longer term basis, and comparing it to the existing budgets as
I have been able to reconstruct them, which is difficult, I would guess
it runs something on the order of $10 million over a 5-year period;
something like that.

Chairman Pepper. Excuse me.

You mean $10 million for 5 years ?

Mr. Jaffe. Distributed over a 5-year period.

Mr. Perito. Mr. Jaffe, do you know how much is now being spent on
such efforts by the Federal Government ?

Mr. Jaffe. No ; I do not know precisely. I have some bits and pieces
of information about what particular subagencies are spending, but
that is all.

Mr. Perito. I assume then, based upon your contacts, vou would
conclude that the Federal Government is spending something mini-
mal, at best ?

Mr. Jaffe. Oh. very minimal.

Mr. Perito. If you were assigned the responsibility of policing an
international narcotics treaty, wherein all the signatories would agree
not to Arrow poppies, do vou believe this technological approach could
be used by the International Narcotics Control Board, for example,
to police throuflfh satellite surveillance the cultivation of poppies?

Mr. Jaffe. The use of satellite surveillance may not be available to
us in the immediate future. But high-flying aircraft, and ultimately
the use of satellites, will provide that kind of capability. It would sig-
nificantlv contribute — in fact, it is difficult to imagine how such a
treaty would be enforceable without such surveillance or something
equivalent.

Mr. Perito. At the present time, do you know of any accelerated re-
search concerning an international data bank?

Mr. Jaffe. I don't have anv specific knowledge about that; no.

Mr. Perito. Do you envision that a data bank could be set up so
that you could have input from several countries and protect the dis-
closure from those people who should not get disclosure ?

In other words, can you envision a data bank which would suffi-
ciently service an organization like Interpol, yet at the same time not
be available to the individuals who could wrongfully profit by this
information ?

Mr. Jaffe. The question of security in data banks has received a lot
of attention of late, and I would suspect that the probability is it could
be done as well as it coud be done in any other area. I think that could
be effected.

Chairman Pepper. Just one question before the other Congressmen
inquire.

Mr. Jaffe, would it be possible to develop any sort of technical
method by which you could detect the conversion of morphine base
into heroin as it takes place in the laboratories of southern France by
flying over the area where the laboratories are located?

Mr. Jaffe. Yes ; I think there is at least a sufficiently good chance
of that being done so that it deserves more attention than it seems to
be getting.

Yes; as Dr. Yondorf is saying, that would be susceptible to counter-
measures, and one gets into this problem which the military faces, of
countermeasures and counter-countermeasures. But I don't think that
is a sufficient argument not to take the first step ; that is, for us to take
the initiative in trying to locate those laboratories, especially from the
air.

Chairman Pepper. Mr. Brasco, do you have any questions ?

Mr. Brasco. Yes.

I am sorry I am late, Dr. Jaffe. This is rather interesting.

I didn't get a chance to go through the beginning — that we do have
at this time such devices or are you suggesting the $10 million go into
the research and developinent of such devices ?

Mr. Jaffe. I am saying that there is a very limited effort under
way on the development of such methods.

Mr. Brasco. But we don't have the devices that you are speaking
about ?

Mr. Jaffe. Generally not of the various things I have spoken about.
Generally they are not available in an operational sense. They are not
being used on the street by enforcement agencies.

Mr. Brasco. This $10 million that you were speaking about is the
cost of the entire project? Is that the cost for the entire project, as
you set forth in your summary ; that is, locating, detecting, developing
the dragnet work and improving the resource management?

Mr. Jaffe. Yes; provided that you understand that that does not
mean it includes the operational costs, the cost of using it. That figure
is the cost of a research and development program that should produce
such results.

Mr. Brasco. I understand. Now, what would then be the cost after
it is produced, if you have any idea, of putting it

Mr. Jaffe. That is really a little bit out of my realm, and I don't
know. For example, if we developed a technique for overflying, what
it costs to run an aircraft for an hour I really don't know. But it
would be that sort of thing.

Mr. Brasco. How long, if you had the $10 million, do you think it
might take to develop such a program ?

Jaffe. Well, there would be some immediate results or very early
results, and they would be distributed.

Mr. Brasco. I know you said 5 years, but are you saying it is 5 years
before any of the equipment could be used ?

Mr. Jaffe. I use tlie 5 years only as a way of averaging cost.
There is no significance in the 5 years, in terms of when results
would be available. I would expect there to be a stream of results
over a longer period of time, too. Just as a way of averaging the cost
I say I think that the program might run something like $10 million
over a 5-year period. If you like, say an average of $2 million a year
or something like that.

Mr. Brasco. I wasn't inquiring so much about the money. I was con-
cerned about when it might be operational.

I am trying to find out when you would have a system that you are
talking about? I am not trying to pin you down, just trying to get
an idea.

Mr. Jaffe. I think it might be as early as a year before we can spot
poppyfields from the air, or a fraction of a year, within a year.

Some of the other techniques, the establishment of a model for
example, and the operation of that, generally takes longer because
there are long periods .of validation necessary while you test the thing
out and make sure you got the right model.

So there are differences. I think that sensors, for example, might
run 1 to 2 years, something in that period, or even less.

Chairman Pepper. Dr. Yondorf ?

Dr. YoNDORF. Thank you, Mr. Chairman.

I would suggest that sensing from satellites would require much
more development. It is easier with our pjresent technology to identify
poppyfiields with airborne sensing equipment; that is, with minor
adaptations of sensor equipment now existing on aircraft. On the
political problems of flying over foreign territory with aircraft, you
are more expert than I am, but technically this is where one should
start. Sensors aren't sufficiently discriminating now to identify crops
from very great altitudes. Research and development money initially
should be spent to develop more sensitive sensors and test them out.

Mr. Brasco. Thank you.

Chairman Pepper. Mr. Wigsins.

Mr. Wiggins. I have no ouestions, Mr. Chairman.

Chairman Pepper. Mr. Mann.

Mr. Maxn. You imply that the governmental efforts beins: made
now in these areas are minimal. Are they doing anything with refer-
ence to opium crop detection capabilities, sensor devices?

Mr. Jaffe. Yes; they are. In fact, with the exception of the data
bank on which I was not able to uncover anything, something is being
done in each of the other areas. There is something being done on the
question of surveillance from the air, and some of the others — the
sensors and tracers, too. There is some very limited modeling going on.

Mr. Mann. Dr. Yondorf, you sujrgested that aircraft surveillance
to develon the techniques is a preliminary step to developing a satel-
lite capability.

Do you think a satellite capability is possible ?

Dr. Yondorf. We do think it is possible. It is just a matter of refin-
ing existing techniques. Of course, one can ai-gue Ihon from which

altitude the satellites should operate. We have satellites that go up
to 22,000 miles— synchronic altitude— and it probably is extremely
difficult to see poppies from that altitude.

But low altitude satellites might well attain the discrimination one
would need for this purpose.

Mr. Mann. Mr. Jaffe, are you aware of any aerial surveillance, aerial
efforts made by the United States of poppyfields?

Mr. Jafte. No ; and those who are in a lot better position to have
heard of any such things tell me that they are 99 percent sure that
there is no such thing in existence. To date, no aerial surveillance has
been made of poppyfields.

Mr. Mann. Well, is my information correct that there are poppy-
fields in areas of this world. Southeast Asia, for example, where we
have a lot of aircraft operating ?

Mr. Jaffe. That is true.

Mr. Mann. No further questions.

Chairman Pepper. Mr. Steiger.

Mr. Steiger. Thank you, Mr. Chairman.

Just a couple of questions, Mr. Jaffe.

Incidentally, I for one find your presentation very interesting as
opposed to my colleagues' rather casual interest. I wonder if you have
heard of the work of Joe Zabitzi — and I can't tell you how to spell it,
He works for the USGS and has developed infrared photography pri-
marily in the search of water resources and has developed

Mr. Jaffe. I have heard of the work they are doing, but the name is
not familiar.

Mr. Steiger. I think it might be of interest for you gentlemen to
coordinate with him because he has done some very dramatic things
I have seen, and obviously, it coincides completely with the type of
thing you are doing here. I know you are aware of this, but I think
the record should reflect your awareness, since your statement does not.

In all your research and development I would assume you would
suggest the need for security, even in the research and development
phase, so as to at least minimize the opportunity for the countermeas-
ures you referred to ?

Mr. Jaffe. Absolutely ; yes. I certainly agree with that.

Mr. Steiger. I say this because, interestingly enough, Mr. Zabitzi
recited to me a proposal by a gentleman from the private sector, I
believe would be a friendly way of saying it, who asked him if he
could find poppyfields for him. He was on a United Nations mission
in North Africa, and he was asked if his technique would show up
poppyfields.

This fellow, who said he was a horticulturist, which I thought was
interesting, indicated that he would be willing to pay for the informa-
tion as to the location of the poppyfield.

So there is an awareness among the group.

Mr. Wiggins. Horticulturists ?

Mr. Steiger. Among the horticulturists.

That is all, Mr. Chairman.

Chairman Pepper. Mr. Rangel.

Mr. Rangel. Mr. Jaffe, in the course of your studies, upon what do
you base the assumption that the United States does not know where
these opium crops are located or where the laboratories are ?

Mr. Jaffe. Primarily on the fact that there seems to be more than
casual interest among the enforcement agencies in techniques of this
sort when we do talk to them about these things. From the fact that
they have some ongoing programs in these areas, one would assume
that they don't know precisely where the fields are or where the labora-
tories are. And it is just information of which I don't have firsthand
knowledge, but I think pretty good secondhand knowledge.

Mr. Rangel. Well, in view of the fact that we have — at least I think
we can admit we have — U-2 surveillance aircraft, we have been, able
to detect missiles in Cuba, we have been able to determine areas of
vegetation in Vietnam and Korea before this, and in view of the fact
rhat we have a very close economic relationship with the countries that
we are mentioning that are considered to be friendly to us, and so
therefore there is an assumption that Government is cooperating with
us, it seems to me that all of the information would lead us to believe
that we know exactly where the crops are located and where the labora-
tories are.

Mr. Jaffe. I think there is a difference between knowing generally
where they are and knowing specifically where they are. It strikes
me that that really is the difference that we would be getting at with
technology.

Mr. Rangel. Well, have you studied any of the reports of the sophis-
tication of our U-2 aircraft ?

Mr. Jaffe. Well, I know generally about what they can do, about
their operational capabilities.

Mr. Rangel. And the information has been rather specific ?

Mr. Jaffe. Yes.

Mr. Rangel. And if we can send these aircraft over unfriendly na-
tions, I just presume we can send them over friendly nations.

Mr. Jaffe. I would agree.

Mr. Rangel. And if we can do all of this I presume that we have
the knowledge that we want already.

Mr. Jaffe. I can't disagree with your presumption. The informa-
tion I have is that the locations are not precisely known over a period
of time. Obviously if they detect one, if they find it, they know where
that one is, but

Mr. Rangel. If my presumptions are correct, we don't need any more
research and development?

Mr. Jaffe. The location of a laboratory, for example, from the air,
does require additional research and development. There is no suitable
way at the moment of overflying or finding a laboratory.

Mr. Rangel. We can find missile bases but we can't find laboratories ?

Mr. Jaffe. Correct; because the laboratory, from the air, looks like
nothing more or less than an ordinary house, somebody's private home.

Mr. Rangel. Even with information given to us by so-called
friendly nations ?

Mr. Jaffe. Well, I don't know about that part of it.

Mr. Rangel. Well, let me ask you one last question, Mr. Jaffe. As-
suming that we did get the refined sophisticated type of research and
development that you are suggesting; after we got it, what would you
suggest we do with it ?

Mr. Jaffe. AVell, all through my remarks I stressed the need to have
the research and development program aimed at the operational needs

of the enforcement agencies. So presumably, the output would be some-
thing which is immediately operationally useful to an enforcement
officer.

The next step, then, would be to turn it over to him and let
him use it.

Mr. Rangel. Have any of the law enforcement agencies in the United
States ever requested this type of support that you know of ?

Mr. Jaffe. Yes. They have ongoing programs, and I have discussed
with them the magnitude of those programs. I think I can say that
there is a need and they would agree to a need — not everyone, you
know, of course. If you talk to the guy about his little laboratory he
says this is fine, this is my kingdom.

Mr. Rangel. Is there any agency that has a mandate to eradicate the
international trafficking of drugs, that has gone on record in asking
for more Federal assistance in the area you have testified to ?

Mr. Jaffe. I don't know. I really don't know.

Mr. Rangel. Thank you.

Chairman Pepper. Excuse me just 1 minute.

Mr. Jaffe, as I understood the import of your testimony, you were
assuming that if we had an international treaty or agreement that
would ban the growing of the opium poppy then if somebody were
to plant a field of opium poppies it could be detected by surveillance
methods so that the policing could be effective ?

Mr. Jaffe. That is exactly right.

Chairman Pepper. Is your information the same as mine, that these
laboratories in southern France are moved around from place to place,
from time to time, so there is no fixed location?

Mr. Jaffe. That is true. They do move quite a bit. Some of them are
easily knocked down and set up again somewhere else.

Mr. Mann. To that may I make a statement ?

Chairman Pepper. Go right ahead.

Mr. Mann. I was in Paris last week where I conferred with the
director of the National Police Force, a representative of the BXDD
in Paris, and I came away persuaded that France is making every
effort in cooperating with us and the law enforcement arena to un-
cover the laboratories, that there is no reluctance on their part or no
economic considerations on their part that are interfering with their
cooperation in attempting to uncover these laboratories.

Chairman Pepper. Mr. Winn.

Mr. Winn. Thank you, Mr. Chairman.

Mr. Jaffe, your statement intrigues me, partly because I am on the
Science and Astronautics Committee and I am aware of the work that
has been done in the satellites and sensors by ERTS. How much work
have you actually done on the feasibility of the total systems
approach ?

In other words, have you taken each of the suggested — like the
laboratory detection tracers, sensors — have you actually tried to co-
ordinate all that and put a package together ?

Mr. Jaffe. No ; we haven't really done that in this particular case.
Our organization and others like it specialize in doing that sort of
thing, but in this particular application we haven't yet done that.

Mr. Winn. Well, I don't mean to be rude about that, but I gather
that from your guess of $10 million, because I don't think you are

in the same ball park about what it would cost. But that is ray own
opinion.

I do think you are on the right track, and I wish possibly some-
where m your realm you would try to coordinate more closely these
potentials.

I don't really care whether any law enforcement agencies in this
country or the world have asked you to do it.

I would hope someone with your capabilities would do it, and there
is a tremendous need for it.

Now, on the satellite capabilities, I have no doubt that within a
very short period of time— and I agree with your time schedule that
within a year, we can view from the air, from satellite, the poppy-
fields. Of course, some one might get up on the floor of the House and
say that their poppyfield had been bugged, but I think we are going
to have to use those approaches, and go at it from that direction.

Because here is a program that is already available to us, here is a
program where we have spent millions of dollars trying to use the
science and technology research capabilities of these men. These are
the same men whom we are now putting out of jobs because some of
our programs are being phased out, and we could use their ability to
help solve some of the drug problems in the country.

I think you are on the right track. I commend you for your state-
ment and I hope that possibly you can put some additional informa-
tion in the record as far as coordination is concerned.

Thank you very much.

Chairman Pepper. Mr. Keating ?

Mr. Keating. No questions, Mr. Chairman.

Chairman Pepper. Mr. Brasco, any questions ?

Mr. Brasoo. Yes, I wanted to ask one question and make an
observation.

I heard several times about an agreement being necessary, but it
would appear to me if we are talking about satellite surveillance I
don't know if we need any agreement to use that kind of technique,
and I think it makes it more attractive because of that because you
are apt to get an arrangement where you can perfect the equipment
before you get an agreement. But the one question I would like to
ask in connection with the sensors that you spoke about, which ap-
parently would detect the drug, you mentioned that they were not
of sufficient capability at this time to be possibly used in satellites.

Could you use whatever equipment you have now, and are they
using it, anyone, if you know, at points of entry in the United States
just to detect it, if someone has it, you know, in a bag or on their
person, or somewhere in the vicinity of the airport or the seaport?

Mr. Jaffe. First of all, there are really two different classes of
things that we mean when we talk about surveillance from the air and
sensing at a point of entry. The techniques for detecting opium fields
from the air are generally available. They just haven't been applied in
this direction and haven't been adapted to this application.

Mr. Brasco. How about the latter one that I was talking about ?

Mr. Jaffe. On the latter one. the Bureau of Customs does have a pro-
gram underway in that area. I don't know of anything being used now.
I don't think anything has progressed to the point where it is being
used now.

ISIr. Brasco. Is that a possibility, in your opinion, to develop that
kind of thing:?

Mr. Jaffe. Very much so.

Mr. Brasco, That obviously is not included in the program you are
talkinof about now ; or is it ?

Mr. Jaffe. Yes ; it is included in the program suggested.

Mr. Brasco. How far might we be away from getting something like
that effected? I am talking about — let's take away the satellites and
the other kinds of survellances that we could develop something that
customs agents could use for detecting on peojjle, in bags, what have
you, on ships coming into the United States.

Mr. Jaffe. I think with the right kind of program, on the order of a
year.

Mr. Brasoo. Do you have any idea as to what that specific item would
cost, just that item.

Mr. Jaffe. That is so hard to do without sitting down and working
it out for that particular application.

Anybody want to guess ?

Mr. Brasco. Xo idea ?

Mr. Jaffe. It is very easy to say on the order of a half a million
dollars to a million dollars, something like that.

Mr. Brasco. Thank you. Dr. Yondorf , do you have anything to add
to what Mr, Jaffe has said ?

Dr. YoxDORF. I generally agree, but not with his numbers. I, person-
ally, guess — I haven't made a survey — that this research could be very
much more expensive, as Mr. Winn has said. How much more is diffi-
cult to say. The sort of thing one would try to permit detection at entry
gates would be some simple thing first, perhaps several techniques in
the area of spectrum analysis. If it doesn't work one would have to try
many other techniques. I don't think we have done enough research,
certainly not any of us here, to have a very good feeling of what mag-
nitude of effort would be required if at first simple things don't work.

First feasibility tests — this is indeed what we suggest here — can
be undertaken and some results gotten within a year. But before one
can make a solid estimate as to how^ much more work is required one
has to have that feasibility study under one's belt. We haven't done
that.

Mr. Brasco. Notwithstanding disagreement with respect to the num-
bers, but you do agree with Mr. Jalfe's position that it can be done?

Dr. Yondorf. That can be done ; yes.

(For more detailed statement concerning proposed research and de-
velopment program see exhibit Xo. 8(a) page 101.)

Chairman Pepper. Mr. Holden, would you add anything?

Mr. Holden. Perhaps just a statement in regard to Mr. Rangel's
point that the militaiy has been flying IJ-2's all over the world and
satellites surveying, apparently, anything of interest. So why haven't
we done this — located illicit poppyfields? It is a question of where
we, as a government, point our cameras find which budget pays for
what type of surveillance coverage.

It is obvious the military has done a lot of work in this area of
aerial and spatial surveillance. The point here is that this activity
ought to receive its fair share of the budget to apply survellance tech-
niques to the fight on drug abuse.

100

Chairman Pepper. Mr, Waldie, do you have a question?

Mr. Waldie. Well, Mr. Chairman, I am intruding in a conversation
that has already occurred, but it seems to me that to invest any great
sums of money in surveying that area of the globe where opiimi is
being grown is moving to the problem in the wrong way. We know
where opium is being grown. It is being grown in Laos. It is being
grown in Burma. It is being grown in Turkey.

It has not been a problem of identifying where the fields are. It is
getting those who grow the opium to curtail production of it. Their
failure to curtail production has not been a failure on their part to
identify where it is being grown.

It would seem to me that money ought to be spent, first, to get
willingness on the part of the governments that own the land on
which the opium is being grown to embark upon a program of eradica-
tion and then, perhaps, to a system in identifying the areas in which
eradication is necessary.

I don't think there is any problem of identifying Laotian opium.
It is participated in by the Laotian Government. They are profiting
from it. Burma opium crops are not any secret ; neither are the Turkey
opium crops. I just am not quite certain why we would invest any
money in aerial surveillance to determine where the fields are that are
growing opium at this point.

Chairman Pepper. I think, perhaps, you didn't get the assumption.

Mr. Jaffe would you state what the assumption was upon which you
recommend the use of these detection devices for growing poppyfields ?

Mr. Jaffe. First of all, the idea that there is no one route, there is
not lust one thing that needs to be done and that the aerial surveillance
of the opium fits into a total scheme of things which would include
such things as international agreements, which would then have to be
enforced, and violations of that treaty would have to be detected.
From there we get to the aerial surveillance. That is one route, to get
to the aerial surveillance.

But it is within the total scheme of things, we think, that aerial sur-
veillance plays a part. I would agree that in the case of Laos there may
be no, or very little reason to want to know where each field is
precisely.

But I think the reasons in Turkey and other countries that are
closer and friendly, the reasons become somewhat more compelling.
It is one thing to have an agreement from them to limit the growth of
opium. It is another thing to be sure that it is actually happening and
to know where it is and isn't happening.

It is in that context that we propose to use it.

Chairman Pepper. Gentlemen, if I understand it, you surmise, as did
Assistant Secretary of the Treasury Rossides. that the bringing in of
heroin to this country is effectuated largely by an international con-
spiracy of people who are perpetrating that crime in order to make
hundreds of millions, if not billions of dollars, a year. They are ruth-
less, they are well organized, they are ably directed.

In other words, it is a criminal conspiracy of great magnitude.

You are suggesting that if we are to be effective against that kind
of an international conspiracy to bring opium into this country and
distribute it we must employ or we should, to be most effective, employ
the most modwn techniques and the most comprehensive program for
dealing with it ; is that the theme of your statement ?

101

Mr. Jaffe. I think it is a very precise statement of the case.

Chairman Pepper. Thank you very much.

Have you anything for the record, Mr. Perito ?

Mr. Perito. Yes, Mr. Chairman.

May we place in the record the supplemental statement and curric-
ulum vitae of Mr. Jaffe; also, the prepared statement of Mr. William
S. Ulrich, which was unfortunately omitted from our New York hear-
ings, but relates to the statements made by Mr. Jaffe, Dr. Yondorf,
and Mr. Hoi den.

Chairman Pepper. Without objection, they will be received.

(The material referred to follows:)

[Exhibit No. 8(a)]

Supplemental Statement of David Jatfe, Department Staff, MITRE Corp.

The suggested research and development program consists of five major parts.
In what follows, each part is further defined in terms of tasks, products, and
probable cost. The cost estimates are related to performance periods, as
appropriate.

The structure of these efforts is highly variable, and the corresponding per-
formance period and cost will be sensitive functions of the approach selected.
A conservative approach can be taken in which ideas are investigated one at a
time, or a redundant program can involve several simultaneous efforts with the
same objective. The cost estimates given below are for conservative approaches.
They are subject to considerable flexibility and interpretation and should be
taken as gross values appropriate only for initial planning.

(1) Surveillance of Opium Poppy Crops

An initial experiment would establish the basis for assembly of test apparatus.
After evaluation of the test gear, designs would be finalized and prototype equip-
ment, suitable for aircraft-bome operation, would be constructed and tested.
Culminating in delivery of the prototype instrument with operating procedures,
this effort might cost about $2.5 million and take 1 to 2 years. The prototype
instrument would be suitable for use by operational agencies in verifying func-
tional utility and in specifying future procurements.

Satellite observations would at first make use of data from available instru-
ments. Only then could the possible need for special hardware be determined.
Depending on the results of initial experimentation, this project could cost
between $500,000 and $2 million. The lower figure presumes ability to use avail-
able data ; the higher one would be the cost of a special instrument package
suitable for flight on a satellite.

(2) Tracer Technology

This effort would consist of identifying tracer materials which could be used
in a variety of operational situations. Contracts would be let to chemical research
firms to develop specific tracers which would be subjected to tests for suscepti-
bility to detection and countermeasures. The product of this effort would be
recommendations to the enforcement agencies for use of a variety of tracers.
Costs are estimated at $1.5 million over a 2- to 3-year period.

(3) Sensor Technology

Techniques known to be capable of identifying heroin would be rated as to
their potential for meeting the constraints of the operational situations. Con-
tracts would be let for redesign of the two best possibilities and for tests of
techniques which might prove to be applicable. Prototypes of the most promising
designs would be constructed, tested, and made available to enforcement agencies.
A continuing effort would be devoted to finding additional useful concepts and
designs. In a 5-year period, it is expected that three or four prototypes would
be completed at a total cost of about $4 million.

(4) Data Handling

A computerized data bank would be designed using information on all facets
of illicit drug production, distribution, use, and control. Information to be in-
cluded would be determined by the operational requirements of the enforcement

102

agencies and input data would be supplied by those agencies. The agency charged
with maintaining the data bank would be provided with a complete system
design, including performance specifications for hardware and software. They
would also receive technical assistance during the implementation and testing
phases. Total cost of this effort is estimated at about $1 million.

(5) Netivork Modeling

Drug production and distribution networks, and their economic systems, will
be simulated by mathematical relationships and other representations. The
models will be operated to reveal sensitivities and vulnerabilities of the illicit
trade. This project is viewed as a joint effort by the model developers and a
user agency for 5 years, after which the model will be run entirely by the agency.
The 5-year cost above the normal agency costs will total about $1 million.

[Exhibit Xo. 8(b)]
Curriculum Vitab of David Jaffe, Department Staff, MITRE Corp.

EDUCATION

Brooklyn College, B.S., 1951, physics and math.
University of Connecticut, M.S., 1952, physics and math.

Additional graduate courses in solid state physics, mathematical statistics, and
magnetic resonance.

EXPERIENCE

The MITRE Corp., September 1970 to present :

Department staff. Concerned with the application of technology to criminal
justice systems. Communications, information systems, sensors and alarms, and
specialized technology are the subjects of these efforts. Methods of approach
include operations analysis and systems engineering.

Research Analysis Corp., October 1965 to September 1970 :

Deputy head, public safety department. Developed program concepts for
research in law enforcement and the administration of justice. Directed studies
including the relationship between the physical environment and crime rates,
logistic support to police and fire departments in combating civil disorders, the
development of specifications for techniques and devices in the prevention of
burglary, the role of the police in a ghetto community, and others.

As deputy department head of RAC's unconventional warfare department,
conducted studies of dissident and insurgent grouns. their modes of operation,
and their vulnerabilities. Assessed national threats from internal and external
population segments. Investigated the feasibility of techniques designed to
measure magnitudes of insurgent activities.

American Machine d Foundry Co., Alexandria Division, 1959 to 1965:

Assistant manager, space instrumentations department. Directed the re-
research and development activities of about 30 men. This group, consisting of
physicists, electronic engineers, and mechanical designers as well as support per-
sonnel, specialized in the conception, design, development, fabrication, and test-
ing of scientific instrumentation, primarily for use on satellites and rockets.
Areas of primary competence include X-ray. optical, and microwave instrumen-
tion and measurements. A major nroject was the design and constrnrtion of soft
X-ray solar spectrometers for flight on Aerobee rockets and the OSO series of
satellites.

As head of physics section, directed experimental and development programs
in general phvsics. iuf'luding classical and quantum disciplines. Tvnimi pro-
grams were the investigation of gaseous microwave spectroscopy involving ex-
tremely sensitive receivers ; visible signals in space, their sources, and their
interactions: develonment of specialized ontical and electro-ontiral sy--tenis and
instrumentation: ion and atomic beams for space communication: parametric
amplifiers: the generation of submillimeter waves: standardization measure-
ments on microwave components: microwave attenuation in dielectric materials.

Diamond Ordnance Fuze Lahnrntoric^. iri"> to 1959.

Conducted theoretical and experimental studies of the behavior of ferromag-
netic materials at microwave frequencies. Investigated ferromagnetic resonance
in ferrite and garnet materials to develop a microwave detector. Measured the

103

magnetostrictive behavior of ferrites. Made infrared measurements of ferrite
materials.

Ballistic Research laboratories, 1953 to 1955 :

Employed high resolution radioactive tracer techniques in the investigation of
internal ballistic effects. Designed and constructed scintillation and photomulti-
plier systems for detection and location of radioactive sources.

Naval Ordnance Laboratory, 1952 to 1935 :

Designed tests and associated equipment for the evaluation of electronic and
magnetic underwater ordnance components. Included were opertaional, life, and
environmental tests. Designed an automatic and fast-operating open-circuit tester
for a complex cable harness.

HOXORS

Sigma Pi Sigma (physics) .

PUBLICATIONS

D. Jaffe, J. C. Cacheris, and N. Karayianis, "Ferrite Microwave Detector,"
Proc. IRE, 46 (3) : 594-601, March 1958.

D. Jaffe, Cacheris, and Karayianis, "Detection of High-Power Microwaves by
Ferrites and Garnets," Diamond Ordnance Fuze Laboratories, TR-867, Wash-
ington, D.C.

D. Jaffe et al., "Some Aspects of Indicator Analysis," Research Analysis Corp.,
RAC-S-1900, McLean, Va., 1966.

Other reports classified or proprietary.

[Exhibit No. 9]

Prepared Statement of William F. Ulrich, Ph. D., Manager, Applications
Research, Scientific Instruments Division, Beckman Instruments, Inc.,
Dated June 27, 1970

Scientific methods have numerous applications in law enforcement programs
including the detection and determination of narcotics and dangerous drugs. Yet,
utilization of modern technology still falls short of its potential in this field. I
appreciate the opportunity to comment on this point and to discuss areas in which
positive action might be taken.

To a large extent my remarks are based upon discussions with individuals
from various law enforcement agencies throughout the country. Almost without
exception, these people have been cordial and most helpful in describing the
needs and practices in their diverse operations. From their comments it is obvious
that narcotics and dangerous drugs, which only a few years ago were encoun-
tered rather infrequently, now represent a major factor in their daily workloads.
Furthermore, the problem is not restricted to major population centers but can
be found in virtually all sections of the country. To combat this, mre effective
methods are needed for handling the large number of samples processed each
day. Even more desirable is the development of new technology which will pro-
vide an effective means for halting production and preventing distribution of
illicit materials.

In evaluating technology in this regard, several distinct areas merit consider-
ation. The first and perhaps simplest of these is to improve the utilization of
techniques and methods which have already been developed within this field.
In an age when communications permit instant transmittal of information and
computers can be used for storage and retrieval, much of the technical informa-
tion within the law enforcement field still follows a relatively slow and haphaz-
ard path. Several publications are devoted to this purpose but even with these
information is often delayed. Even worse is the fact that much of the infor-
mation either is not published at all or is published in journals or internal publi-
cations which are not readily available to other workers. Certainly this is not
an insurmountable problem but it does require an organized program which
w^ould encompass all efforts in this field.

A related area to be considered is the utilization of technology developed in
other disciplines. Many of the techniques and metbod^ applied for the life
sciences, space research, environmental control, and other areas can serve
equally well in the law enforcement field. In fact, this has been the basis for
much of the technology now in use. However, for this to be truly effective,
greater contact with these disciplines must be fostered.

In both of these areas, there should be greater opportunity for law enforce-
ment scientists to devote time to development efforts. With present workloads.

104

most facilities are barely able to handle daily problems let alone give thought
and attention to new and improved methodology. Only a relatively few lab-
oratories are able to do this type of work and even in these much of the effort
is performed on an ott-huurs basis. Until this situation is improved, technical
advancements will be slow and inefficient.

In assessing opium products, more specific objectives can be considered. Es-
sentially, this market can be described on the basis of classical supply and de-
mand principles. Greater control can be achieved either by restricting the
supply or by decreasing the demand. The latter involves a host of social, en-
vironmental, medical, and other factors. Technology participates in these but is
not a dominant factor.

On the other hand, scientific methods can and do play an active role in com-
bating the production and distribution of illicit narcotics. Current technology
provides simple and reliable procedures for identifying and quantitatively
determining these substances even when they are heavily diluted with excip-
ients or present in minute quantities. Unfortunately these methods are applicable
mainly to seized materials and are relatively ineffective for interception pur-
poses. Thus, they are more useful for prosecution than for prevention whereas
ideally the latter would be preferred. Therefore, more consideration should be
given to the development of remote sensing and tracer techniques.

In terms of opium products, at least six discrete points can be identified where
technology can be applied :

(1) The point of origin; namely, the naturally occurring or cultivated crop.
This represents an ideal point at which specific tracers could be added.

(2) The facilities where the raw material is refined and processed to yield
high-grade morphine and heroin. Surveillance here might be facilitated by de-
tection of the chemical reagents utilized or emitted during processing.

(3) The port of entry where the illicit material is brought into the United
States.

(4) The secondary processing facility where bulk samples are diluted and
repackaged.

(5) Transportation to the ultimate user.

(6) The user, his dwelling or property.

Each of these represents a unique set of circumstances and levels of difficulty.
For example, chemical detection of material in sealed containers is far more
difficult than when it is being processed or otherwise exposed to the atmosphere.
In the first case, it may be necessary to open the container for detection whereas
in the latter even remote sensing is conceivable. In terms of need, interception
near the source is more desirable than at the ultimate user because of the
quantities involved. The point to be made is that interception is not a simple,
single concept but rather a set of individual opportunities each of which
should be examined on its own merit. Therefore, an approach similar to that
used by systems-oriented technologists can be visualized. A simplified outline
of such a program might involve the following steps :

(1) Clearly define primary and secondary goals.

(2) Research and evaluate existing state-of-the-art or level of knowledge
of the known and presumed technology which may be involved.

(3) Outline all approaches conceivable for achieving the specified goals.

(4) Evaluate current feasibility of each approach, the manner in which these
interrelate, and the potential for their practical application.

(5) Select the approach or approaches which should be pursued as based on
social and economic factors and the probability of technical achievement.

(6) Design, develop, and test the new technology, systems, and procedures
and apply to the problem.

(7) Continually evaluate the effectiveness of each approach to insure it con-
tinues to move toward the specified goals and to detect new approaches which
might evolve from the advancing technology. , , i ,

Depending upon manpower and other resources, parallel efforts should be
considered as a means of providing answers in the shortest period. At the out-
set a program should be undertaken to evaluate current capabilities and knowl-
edge which exist within the various agencies of the Federal establishment, inter-
national organizations, academic institutions, and private iiulustry It may well
be that technology already exists for this purpose and only needs to be directed
to the proper aL^encies for exploitation. At the very least, such information would
be of considerable value to law enforcement programs at all levels and even to
external groups such as those engaged in medical research.

105

I would do this committee a serious injustice to suggest that a simple, fool-
proof detection device is just around tlie corner. Ratlier, it seems likely that
progress will be made in orderly steps which ultimately will provide effective
deterrents to the illicit traffic. I urge this committee to provide support and en-
couragement to such a program.

Chairman Pepper. Will Dr. Frances Gearing please come forward?

The committee is pleased to welcome now Dr. Frances Gearing. In
addition to her medical degree. Dr. Gearing holds a master of pnblic
health degree from the Columbia University School of Pnblic Health
and Administrative Medicine.

Since 1957, Dr. Gearing has been associated with the Columbia Uni-
versit}' School of Pnblic Health and Administrative Medicine, where
she now holds the rank of associate professor of epidemiology.

Since 1967, Dr. Gearing has served on the Xew York State Narcotics
Commission's advisory committee on criteria for funding narcotics
treatment pi-ograms. This year, she was appointed a member of the
professional advisory committee on heroin addiction of the District of
Columbia Department of Human Resources.

Since 1965, Dr. Gearing has been director of the evaluation unit
for methadone maintenance treatment program for heroin addic-
tion, in which position she has supervised a comprehensive study of the
efficacy of methadone maintenance and its relationship to crime control.

Dr. Gearing, we w^elcome your testimony on this matter of critical
importance.

Mr. Perito, will you inquire ?

Mr. Perito. Dr. Gearing, we understand that you have conducted
several studies on the relationship between the use of the methadone
modality treatment approach and the decrease in crime by addicts
under such treatment ; is that correct ?

STATEMENT OE DR. FRANCES R. GEARING, ASSOCIATE PROFESSOR,
DIVISION OF EPIDEMIOLOGY, COLUMBIA UNIVERSITY SCHOOL
OF PUBLIC HEALTH AND ADMINISTRATIVE MEDICINE

Dr. Gearing. Yes.

Mr. Perito. I wonder if you could review for the committee the
approach that you took and the type of studies that have been final-
ized by you or under your direction.

Dr. Gearing. Well, for the record, it is all one study. It is a con-
tinuing ongoing evaluation.

We have looked at it in several ways. First of all, we did before-
and-after pictures of what has happened to the patients who have been
admitted to the program, looking at their previous criminal records
and comparing this with what has happened to them since they have
been in the program.

Our latest review would say that you could almost look at metha-
done as some kind of a vaccine against crime and look at it in a vaccine
efficacy-type model and in that light we would say that methadone
maintenance patients have a decrease in their criminality in the first
year of 81.5 percent ; in the second it is about 92 percent; in the third
year, 96 percent ; and for those who stay in the fourth year, it comes
close to 99 percent. That is using the same patients' previous crim-
inality records as a basis for comparison.

60-296 0—71 — pt. 1 S

106

We have also studied a ^roup of addicts who have been admitted to
the detoxification unit at Morris Burns Institute in New York City.
This is a short-term drym^ out process where they remain in the facil-
ity for approximately 2 weeks, .qfettintr decreasing: doses of methadone.

We matched these people with patients in the studv populaHon and
looked at their criminal records pr'or to time of admission in detoxifi-
cation and what has happened to them subsequentlv.

The contrast is rather strikinsj. The detoxification does not prevent
crime. Their records, since under our observation, are no different than
thev were prior to admission for detoxification.

Mr. Pertto. Dr. Gearina:. how large a samplinq; did vou use? Did
you use the entire group when you did this profile analysis that you
gave us from 81.5 to 99 percent?

Dr. Gearing. The figures I gave you of the 4 years would be the first
1,000 patients admitted to the pro.qrram. I have another figure for the
first 600 patients who were admitted on an ambulatory basis. The
figures are roughly similar.

Mr. Pertto. The first 1,000 patients, I take it, those were not all
ambulatory patients ?

Dr. Gearing. None of them were.

Mr. Perito. How long were the addicts confined for treatment ?

Dr. Gearing. Six weeks.

Mr. Perito. Then released and come back on a periodic basis ?

Dr. Gearing. No ; they are released, then, to an ambulatory or out-
patient clinic unit where they come in initially every day for their
medication and gradually twice a week.

Mr. Perito. Did you personally secure the raw data or was it pre-
sented to you by people working in the program ?

Dr. Gearing. No, sir ; the majoritv of the data we secure ourselves.
Our prime source is from the New York City narcotics register, as re-
ported from the police.

However, the data that we get from the program would tend to show
that it is very useful, too, because the patients do report to the program
when they are arrested because legal counsel is available to them.

Mr. Perito. Did you take a sampling or did you do some personal
interviews with each of these addicts to make a determination as to
their rate, for example, of illegal activity which did not result in some
type of criminal charges being lodged against them ?

Dr. Gearing. No, sir.

Mr. Perito. Do you know of any study such as this in the United
States where the addicts were interviewed as to their criminal activity
as opposed to a pure evaluation of the process ?

Dr. Gearing. No, sir. I think there is a group at Harvard that may
be undertaking such a study in a patient population in New York.

Our charge was to obtain objective criteria for evaluation, and we
tried to make it as obiective as possible and find things that we could
measure, and the things we could measure were arrests and incar-
cerations.

Mr. Perito. And your study of the New York program is ongoing ;
is that correct?

Dr. Gearing. Yes, sir.

Mr. Perito. I understand that you are also about to do an analysis
and efficacy study of the Narcotics Treatment Administration in Wash-
ington ; is that correct ?

107

Dr. Gearixg. I have been asked to consult with them and assist them
and to set up some kind of ongoing evahiation for their program.

Mr. Perito. Now, going back to your New York program, the
statistics, the 81.5 to 99 percent, did those statistics only include the
1,000, or did the amount of patients in that study increase ?

Dr. Gearixg. No; they decreased because I started with 1,000
patients, the first 1,000 patients admitted. Not all of them have been
in the program for 4 years because of the way the patients were
admitted.

Mr. Perito. What was, to the best of your knowledge, the dropout
rate of the first 1,000 patients ?

Dr. Gearixg. The dropout rate is approximately 15 percent during
the first year, about 5 percent in the second year, and about 2 percent
a year for the ensuing years.

Mr. Perito. Did your analysis also include an evaluation of their
return to work or to school ?

Dr. Gearix^g. Yes, sir.

Mr. Perito. Could you tell us what those statistics show ?

Dr. Gearixg. The average employment percentage for patients en-
tering the program during the early phases was approximately 25
percent.

Those who stayed in the program for 6 months, approximately 45
percent of them were employed.

Those who stayed in the program over a year, the percentage goes
up to 55, and for those who have been in the program 5 years or longer,
it is approximately 90 percent.

Of those who were admitted initially on an ambulatory basis be-
cause of the selective process by which they tested the ambulatory
procedure, a higher percentage of them were employed or in school
at the time of admission.

So that their rate of increase of employment is not as great.

However, it levels off to approximately the same figure at 18 months.

Mr. Perito. Dr. Gearing, did you ever have occasion to do a com-
parative study of the drug- free approach in New York ?

Dr. Gearixg. Did I ever have occasion to ?

Mr. Perito. Yes.

Dr. Gearixg. I offered my services. They were not accepted.

Mr. Perito. Do you know of any studies done similar to the studies
which you did on the methadone programs in New York of drug-free
programs anywhere in the United States ?

Dr. Gearixg. I wish I did.

Mr. Perito. To the best of your knowledge, those studies do not
exist ?

Dr. Gearixg. That is correct.

Mr. Perito. Dr. Gearing, you have presented us, kindly, with a paper
which you presented to the Third National Conference on Methadone
Treatment on Saturday, November 14, 1970 ?

Dr. Gearixg. Yes, sir.

Mr. Perito. And also a paper which you gave at Pontiac, Mich.,
on December 2, 1970, and these relate to your studies of the evaluation
of the methadone maintenance approach ; is that correct ?

Dr. Gearix'g. Correct,

Mr. Perito. Are these the two latest studies which you have done ?

108

Dr. Gearing. Yes, sir; I would not consider the position paper a
study. That was a lawyer's confrontation for which I wrote a position
paper.

Mr. Perito. Mr. Chairman, I would at this point ask that these two
papers be incorporated in the record.

Chairman Pepper. Without objection, they will be admitted for the
record.

(The documents referred to above appear at the end of Dr. Gearing's
testimony.)

Chairman Pepper. Just one question before we proceed.

Is it your conclusion, therefore. Dr. Gearing, from the studies that
you have made over a period of time that methadone is the best treat-
ment now known and now available for heroin addiction?

Dr. Geartxg. I wouldn't make quite that strong a statement, ISIr.
Pepper. I would say that for those patients who volunteered for the
methadone maintenance treatment program who have a history of
long-term heroin addiction, this is the best treatment we have at the
moment ; yes.

Chairman Pepper. And you did find a striking diminution in the
amount of crime committed by the people who took methadone who
previously had a heroin addiction ?

Dr. Gearing. Yes, sir. These were patients who by definition, to get
into the program, have had to be known as "criminal addicts." They
had to have had previous infractions of the law.

Chairman Pepper. Have you had long enough experience with these
people who took methadone to determine Avhether it became addictive
with them.

Dr. Gearing. I am not sure the patients who have been on the pro-
gram a long time consider themselves addicted. They consider them-
selves dependent, and happily dependent because it has freed them
from the problems they had when they were chasing heroin.

Chairman Pepper. Did you find the people who took methadone over
a period of time have suffered any apparent trouble or physical injury ?

Dr. Gearing. As far as we can determine, from serial medication
examinations, and the patients in the program 5 years or longer have
been monitored carefully, there seems to be no physical or physiologi-
cal problems.

Chairman Pepper. Yesterday, we had some distinguished witnesses
here who said that they did not think that private physicians should be
authorized to prescribe methadone.

What is your recommendation on that ?

Dr. Gearing. If you will look at the recommendations that the ad-
visory committee and I put together at the end of that last rei)ort, we
make the same recommendation, that it is not for use of the ])hysician
in his private office, because methadone, in and of itself, is only really
a brid.o-e which allows the patients time to get involved in their own
rehabilitation.

The big need, for manv of them, is to gain extra skills, to find a job,
and many other social services.

Chairman Pepper. Mr. Blommer, do you have any questions?

Mr. Blommer. Yes.

109

Doctor, on page 3 of the paper that you have kindly given us, you
show the reasons for discharge from the program as being alcohol
abuse and abuse of other drugs. Now, these figures are relatively
small.

What standards are applied to the people in the program that
could lead to their being discharged ?

Dr. Gearing. Every effort is made in the program to help them
with their problems. It is continual abuse, and inability to handle
their other problems, that may lead to discharge.

But there are supportive services. In fact, particularly in the Har-
lem area, working on the alcohol problem they have one full-time
person. And many of the patients do very well.

Mr. Blommer. Doctor, would it be a fair statement to say that
merely because someone is abusing the program, and by that I mean
not just taking methadone, but also taking alcohol, taking ampheta-
mines, that this abuse would not be grounds enough to drop them from
your program?

Dr. Gearing. That is correct. I think initially they were dropped
from the program for two reasons :

One was the program was not equipped to handle these problems;
and second, there was such a long list of patients waiting to get into
the program; the waiting time had become so long that the decision
on the part of the program people was, "How to do the best job for
the greatest number," and if some patients Averen't making it then it
was better to substitute somebody else. I think that was the philosophv
as I understood it,

Mr. Blommer. In any case. Doctor, if someone has a job, would you
say they Avould most likely be retained in the program, that job being
an indication they were adjusting?

Dr. Gearing. Someone has a job, even though he may be abusing
drugs or alcohol ; definitely.

Mr. Blommer. So that your statistics of people having a job bene-
fits your program?

Dr. Gearing. It is not my program, sir.

Mr. Blommer. Excuse me. The program that you evaluate. The
chart seems to go up, showing that more and more people have jobs,
and the sampling goes down.

Dr. Gearing. It is not the sampling. Remember, patients are being-
admitted all the time. So that at any point in time you have so many
patients in the program only 2 weeks or 3 months. For instance, when
I started evaluating the program there were 66 patients in the pro-
gram. Forty-five of those patients are still in the program, but those
are the only ones on whom I can say I have a 5-year followup, because
that is all the patients who had been admitted at that time.

Mr. Blomer. In other words, there are fewer and fewer patients
that meet the criteria ; is that correct?

Dr. Gearing. No ; the program started 5 years ago with 66 patients.
That is all the 5-year followup patients I could possiblv have, ever:
right?

Mr. Blommer. I see.

Dr. Gearing. Now, in the 4-year followup we have a smaller num-
ber and right now, if I were doing a 3-month followup, I would have

110

somethino: in the nei<rhborhood of 6,000 patients. That is the rate at
■which admissions are being taken on now.
Mr. Blommer. Let me switch topics. Doctor.

Is anyone in the Dole-Nyswander program receiving methadone
maintenance but no therapeutic services?
Dr. Gearing. There is a small group that was started last July.
Mr. Blommer. Have you any statistics on whether they are able to
stay out of trouble and keep jobs?

Dr. Gearing. I have a very short followup on them.
Mr. Bi,0MMER. Is there any trend emerging?

Dr. Gearing. Yes; the dropout rate is somewhat higher. Their ar-
rest record is about the same, and their rate of obtaining new employ-
ment is slightly lower.

Mr. Blommer. The same as the ones who are receiving therapy ?

Dr. Gearing. That is on the first 100 patients.

Mr. Blommer. Would it be a fair statement to say that the trend,
then, is away from therapy as opposed to more therapy ?

Dr. Gearing. No; I would say the trend is an attempt to select out
of a group of patients who need the additional supportive services and
concentrate the supportive services on those who need them the most,
or start with supportive services for patients who seem to need it and
gradually put them into a less-structured program.

Mr. Blommer. I have no further questions, Mr. Chairman.

Chairman Pepper. Mr. Waldie ?

Mr. Waldie. No questions.

Chairman Pepper. Mr. Wiggins ?

Mr. Wiggins. Yes, Mr. Chairman.

Doctor, what is the proper name for this program to which we have
referred in general terms ?

Dr. Gearing. It was ori.qinollv known as the Dole-Nvswander pro-
gram ; later on known as the Beth Israel procrram ; now the Methadone
Treatment Program in New York City and Westchester County, be-
cause it now encompasses, in addition to those units I have mentioned,
another unit in the Bronx and the New York City program which
started the first of November.

Mr. Wiggins. Who is the dire<"tor of the program ?

Dr. Gearing. Dr. Harvey Gollance would be the director of those
portions that come under what is now called the Beth Israel program.

Mr. Wiggins. How do you spell his name ?

Dr. Gearing. G-o-l-l-a-n-c-e, and Dr. Robert Newman is the direc-
tor of the New York City program and Dr. Edward Gordon is the
director of the Westchester program.

Mr. Wiggins. Is this a private program or a Government program ?

Dr. Gearing. Beg pardon ?

Mr. Wiggins. Is this a private program or a Government program ?

Dr. Gearing. It is a projrram, with one small minor exception,
supported by the State of New York Narcotics Addiction Control
Commission.

Mr. Wiggins. So far as you know, are there any direct Federal
grants involved in the program ?

Dr. Gearing. As far as I know, except for perhaps some laboratory
research at Rockefeller University, there is no Federal money in this
program.

11(1

Mr. "VViGGixs. How does a patient qualify for the program, Doctor?

Dr. Gearing. Well, that is a little bit out of my field, but a patient
applies for admission. He is screened and he has to meet certain
criteria.

Mr. Wiggins. Would it be accurate to say that all of the patients
are voluntary?

Dr. Gearing. Absolutely. In fact, they have to sign a voluntary
commitment to take the medication.

Mr. Wiggins. Is there a method, so far as you know, of course in
the State of New York, whereby courts may compel attendance to
methadone programs as a condition to probation, for example?

Dr. Gearing. Compel ?

Mr. Wiggins. Yes, ma'am.

Dr. Gearing. No; I think they can give the patient the option of
taking methadone or going into one of the other nonmedication pro-
grams.

Mr. Wiggins. Have you had any experience in evaluating other pro-
grams in which you might give us some guidance concerning the
wisdom of compulsory methadone programs.

Dr. Gearing. No ; I sort of shudder at the thought of compulsory
treatment programs. I would think that voluntary treatment programs
in prisons might be useful.

I think to legislate medication goes against my physician's blood.

Mr. Wiggins. Yes, ma'am.

You describe in your prepared statement certain security techniques
that are employed to insure that your patients are not using the pro-
gram to satisfy their own drug needs. How is this information au-
thenticated ?

More specifically, let us suppose that a patient qualified, how do you
know that he is not also continuing to feed his heroin addiction on the
street ?

Dr. Gearing. Well, he is periodically tested with urine samples.

Initially, he has a urine sample taken every time he comes in. While
the patients are being built up to their tolerance dose, many of them
do shoot heroin, there is no question about it.

Mr. Wiggins. Will a urine sample detect the presence of heroin ?

Dr. Gearing. No : it will detect the breakdown products, morphine,
and also since we in New York still cut it with quinine, it also detects
quinine.

Mr. Wiggins. In that event you can still tell whether a patient is
continuing to feed his heroin addiction by shooting heroin from th"
street ?

Dr. Gearing. Yes.

Mr. Wiggins. How about the other drugs ?

Dr. Gearing. This is really a program-type question. I happen to
know something about it, but this is not really my field.

The other drugs, amphetamines, barbiturates, methadone, and co-
caine, can be detected in urine. Marihuana and alcohol ; no.

Mr. Wiggins. Let's suppose a patient signs up for and qualifies for
a program in New York City and he also tries to sign up and qualify
for another program to get a double dosage. How is that prevented 2

Dr. Gearing. We are attempting to prevent this in that we have
what is known as a data bank where each patient that applies for a

112

program is put into the machinery and matched by his first name,
last name, and his mother's maiden name, which seems to be more
useful than the birth date, to prevent this kind of duplication.
So far, I think two have been picked up.

Mr. Wiggins. If a person just simply used a different name, would
he be detected ?

Dr. Gearing. No. What purpose would be served by a patient going
to more than one program 'i

Mr. Wiggins. Well, 1 don't know, Doctor. Maybe you can help me.
Dr. Gearing. Because he takes his medication daily. He takes his
medication at the clinic. He is giving no medication to take home.

Mr. Wiggins. I understand that. Would a person who is dependent
upon methadone and had a prior history of heroin addiction, get a
greater euphoric effect, or whatever the impact may be, from a second
dose of methadone than he would from just one ?
Dr. Gearing. You will have to ask the patients. I don't know.
I know the experience with the majority of the patients who have
been in the program for some months, many of them ask to have their
dosages cut down. They do not develop a tolerance like with heroin
where they have to get increasing dosage. At the stabilizing dose, some-
where between 80 and 120 milligrams a day, they don't appear to crave
more.

Mr. Wiggins. Is that conclusion generally held in the medical com-
munity ; namely, that a stabilizing tolerance is achieved with metha-
done programs, unlike other analgesic substances ?

Dr. Gearing. I don't think there is anything about the drug addiction
field that is universally held in the medical profession.

Mr. Wiggins. Do you have any comment about that? Have your col-
leagues, so far as you know, come to a contrary conclusion?
Dr. Gearing. None who work for the program; no.
Mr. Wiggins. Doctor, I gather that there is some diversion in
methadone and that it can be obtained occasionally on the street. What
do you believe is the source of that diversion?

Dr. Gearing. In New York City the source of that diversion is al-
most exclusively the private-practice physician who, in being kind to
his patient, gives him not one dose but several doses, such as a pre-
scription for several doses or a week's supply.

Mr. Wiggins. Do you have any recommendations to this committee
on how that problem might be curtailed ?

Dr. Gearing. I think my recommendation is that I wish that physi-
cians were not giving it in their private offices, but apparently that is
being done.

Mr. Wiggins. Will it be your recommendation that the private dis-
pensing of methadone outside of a control clinic be banned entirely ?

Dr. Gearing. No; the recommendation is that those physicians wlio
are interested in working with drug addicts in methadone maintenance
affiliate themselves wnth some kind of an ongoing progi-am and that as
the patients become stabilized and no longer need the supportive serv-
ices of a total program that the private sector could then take on the
patient.

Mr. Wiggins. Doctor, so far the witnesses agree that methadone is a
dangerous addicting narcotic, and 1 am sure you agice with that
statement.

Dr. Gearing. Yes.

113

Mr. WiGGixs. Is it more difficult to withdraAv a patient addicted to
methadone than it is a patient addicted to heroin ?

Dr. Gearing. No; I think it takes a little bit longer, because the
methadone that they are getting when they are on methadone mainte-
nance is pr-etty good stuff. The heroin that they are getting on the street
is not such good stuff.

Mr. Wiggins. I am going to use a term that may not be appropriate.
I am going to use the term "euphoria." That may not be truly descrip-
tive of the effect on the human body, but you use the appropriate tenn.

What is the difference in the euphoric effect between the use of heroin
and the use of methadone ?

Dr. Gearing. The difference is primarily in the mode in which it is
given. If methadone is injected euphoria is obtained. Methadone given
by mouth, the euphoria, as I understand, it does not occur.

Heroin given by mouth doesn't do anything.

Mr. Wiggins. Methadone is an antagonistic drug; isn't it?

Dr. Gearing. No ; it is known as a block.

Mr. Wiggins. Yes ; but it is not antagonistic.

TVhat satisfies the psychic craving for the euphoric effect if they
don't get it on the methodone maintenance program ?

Dr. Gearing. My judgment Avould be that the heroin addict has two
phases. He has a euphoric phase. He also has a fear of withdrawal
phase. I think that this stabilization seems to block that craving. I can't
answer that any further because I don't know.

Mr. AViGGiNS. Have you observed that there is abuse by shooting
methadone on the streets of New York, for example ?

Dr. Gearing. Very little.

Mr. Wiggins. Is it more dangerous if applied intravenously?

Dr. Gearing. The methadone that is used in the methadone main-
tenance program is theoretically noninjective.

Mr. Wiggins. That i=i all I have, Mr. Chairman.

Chairman Pepper. Mr. Waldie ?

Mr. Waldie. No questions.

Chairman Pepper. Mr. Brasco ?

Mr. Brasco. Yes.

Dr. Gearing, I understood you to say before — correct me if I am
wrong — that the methadone detoxification program as measured in
relationship to criminality was not as successful

Dr. Gearing. I didn't talk about the methadone detoxification pro-
gram. I talked to about 100 patients that we selected out of the detoxifi-
cation program by virtue of the fact that they matched by age and by
ethnic group and time of admission to detoxification unit the patients
in the methadone maintenance program, and we followed this.

Mr. Brasco. May I ask you this. Doctor? In connection with the
methadone maintenance program ; is there anything within the con-
fines of the program itself that leads toward the eventual withdrawal
of all drugs ?

Dr. Gearing. There is no plan in the program for a time when a
patient shall be withdrawn from methadone ; is that what you mean ?

Mr. Brasco. Yes.

Dr. Gearing. Many of the patients ask to be withdrawn with the
notion that they think they can make it on their own, and they are
withdrawn and then they are given the privilege of returning. I think

114

you have some data there that shows that a goodly portion of them do
return.

Mr. Brasco. They do return ?

Dr. Gearing. Although a small proportion of them go into absti-
nence programs.

Mr. Brasco. In connection with dispensing of methadone, I under-
stood you to say that initially the patients took their dosage at the insti-
tution where they entered the program and later on they come twice a
week.

Dr. Gearing. Some of them come twice a week. Some of them never
get beyond the every day. This depends upon a good many things, in-
cluding their own rehabilitation.

Mr. Brasco. I take it those who come twice a week

Dr. Gearing. Yes ; in a locked box.

Mr. Brasco. No ; I wasn't trying to be — I personally agree with your
first statement. Maybe I should have said that first, that this is proba-
bly the best we have to offer.

Dr. Gearing. At the present time.

Mr. Brasco. What 1 was trying to do was to get some answers from
you. The program has been from time to time, as you know, criticized.
One of the things is the incidence of death. I heard some statistics — I
am not saying it is true, I am just saying

Dr. Gearing. That is from what, bv whom ?

Mr. Brasco. Where did we get the statistic, Paul, with respect to
the deaths ?

Mr. Steiger. In children.

Dr. Gearing. Death in children, three.

Mr. Steiger. Six.

Dr. Gearing. Is it six now ? In New York City ?

Mr. Steiger. Here, in Washington, D.C.

Mr. Brasco. In any event, is there any reason why we couldn't have
all of the people in the program report every day for their dose?

Dr. Gearing. It impairs the rehabilitation of the patient. In trying
to be fair to a patient you would like to give him some freedom as he
stabilizes and becomes a productive citizen.

Therefore, this is actually the one punitive measure that is used in
a program, and that is if a patient begins getting into trouble or act-
ing up or abusing other drugs they are put back to having to come in
every day.

At the moment, they are all given weekend medication to take

home.

Mr. Brasco. Just one last question in connection with Mr. Wiggins
line of questioning concerning the fact that some of the methadone
was getting into the streets of New York. That must be measured with
the severe limitations that there are in connection with the program.

I had a young man come to my office several weeks ago, and it took
me a day and a half, calling all oVer the place, trying to find a spot
for him. ,

In any event, I kind of suspect that if the program was developed
i n large cities in the way that you described

Dr. Gearing. The program is expanding astronomically.

Mr. Brasco (continuing). There would never been any need tor it
being dispensed by anyone else.

115

Dr. Gearing. The New York City program, which started on No-
vember 1, was wondering where they were going to get their patients.
They now have a waiting list of over 1,000 patients. They have 3,000
who may be accepted, and money for 2,000, and the other 1,000 will
be waiting.

Mr. Brasco. The question really is : In New York there are mone-
tary limitations?

Dr. Gearing. It is monetary limitations and staffing.

Mr. Brasco. And staffing ?

Dr. Gearing. Yes; and also finding locations which will accept a
narcotic treatment program in the area. Not every area of New York
City, as you may know, enjoys the idea of having a methadone main-
tenance treatment program on their block.

Mr. Brasco. Unfortunately, I do know something about that.

Might we integrate that with a hospital service? Might that help
cut down on that problem ? In other words, use a portion of a hospital ?

Dr. Gearing. This has been done at Delafield and the Washington
Heights Center. There are two units in the Washington Heights
Health Center and one in the Delafield Hospital.

Mr. Brasco. Thank you.

Chairman Pepper. Mr. Steiger.

Mr. Steiger. Thank you. I was very interested, Doctor, in Mr. Wig-
gins' approach on the possibility of the patient continuing his heroin
habit undetected. The urine analysis is the only method that this
program uses to detect the heroin ?

Dr. Gearing. It is the only method there is, as far as I know, and
it only detects heroin taken within the last 24 hours.

Mr. Steiger. I assume they use interviews also; I mean, they ask
them?

Dr. Gearing. The patients squeal on each other.

Mr. Steiger. ^Yhat is the incentive to squeal ?

Dr. Gearing. Pride in the program.

Mr. Steiger. Is there any method you know of, of beating the test,
beating the urine analysis ?

Dr. Gearing. Oh, I am sure there is. The urine analysis is not used
in the punitive sense. It is used primarily for counseling. They don't
shake their finger and say "You have been a bad boy."

Mr. Steiger. An addict who was continuing a heroin habit and had
the desire, he could conceivabl}^ continue it and stay in the program
undetected ?

Dr. Gearing. I wouldn't say undetected; no. There have been, I
think, something like 1 percent of the patients who have been dropped
from the program for continual shooting of heroin after they were
reaching — supposedly — a stabilizinsr dose. The theory here is that in
these patients this treatment doesn't work, obviously.

Mr. Steiger. The ingenuity of the addict is fairly well known. He
will do a great many things to achieve — to acquire — the drug and
use it. It occurs to me that maybe we, as an interested coneressional
committee, might want to explore possibly a more efficacious test.
This would be my only concern, because we have had reports of urine
analysis, the methods of beating urine analysis itself, some very in-
genious methods. It occurs to me it might be worth while to explore a
better test.

116

Dr. Gearing. It depends on what you are concentrating on. Are you
concerned about the urine or the patient ? I really don't know what
difference the urine makes if he has become a productive citizen and
is able to function and is staying out of jail, because I suspect that in
certain groups of the population, we could test for a variety of drugs
and find habitual users, even among such illustrious people as among
our Congress.

Mr. Wiggins. Users of what ?

Dr. Gearing. Drugs, amphetamines, barbiturates, tranquilizers, pep-
up pills, et cetera.

Mr. Wiggins. I just didn't want you to be misunderstood as accusing
Members of Congress shooting heroin.

Dr. Gearing. No. I think in a rehabilitation program of this kind
one can get overly hung up on urine testing, which is a very expen-
sive and time-consuming part of the operation. I think it is very good
from a counseling standpoint to let the patient know that big brother
is watching him, but as far as handling the patient and his problem,
it is not his urine you are concerned about.

Mr. Steiger. The whole problem, it seems to me, the basic objec-
tion to the problem in terms of laymen is we are substituting one
dependence for another, and in this instance we may not even be doing
that. We may simply be mitigating the original dependence.

I would like to ask one question : On urine analysis, have you been
able to get a statistically representative group of people who have been
through the program for a given period, whatever that may be, and
now no longer take methadone and are no longer addictive and are
productive ? Are' there any fisrures like that ?

Dr. Gearing. We are in the process of trying to find those people.
They can find those who haven't made it. That is the easiest thing,
because we can find them through our other reporter services.

We have a group of some 20 percent of the patients who have left
the program that we haven't been able to find through these sources.
We are now in the process of trying to find out what proportion of
these people are, in fact, drug free.

Mr. Steiger. My question is: In your opinion is it possible for
somebody, through the methadone maintenance program, to achieve
independence from methadone and anything else, or do we have to an-
ticipate that he will be a methadone addict for the rest of his life '?

Dr. Gearing. From the information I have at the present time I
would equate methadone maintenance with insulin for diabetics, as
probably a lifelong commitment for many of the patients.

Chairman Pepper. Mr. Mann.

Mr. Mann. Doctor, in your evaluation, what employment problems
or patterns do you find these people having and is the community prej-
udiced or reluctant to employ these neonle ?

Dr. Gearing. The answer to the last question is yes. in some areas.
The experience that has come about in the pro.Qfram is that it is like
getting the first olive out of the bottle. Gettin.q; the first man on meth-
adone maintenance employed in a particular industry or jxroiin is the
tough one. Once they have accepted the first one and thev find out
that he is a useful citizen, then getting other people into that is a
simnler iob. That is one point.

The main point, I think, is that many of them have to be given

117

some kind of skill training in order to be employable above the wel-
fare level, and this has taken some doing and is an active part of
the program.

Does that answer your question ?

Mr. Mann. Yes ; thank you.

Can a person be on methadone and take a periodic heroin shot
for the euphoric effect and incur no increased physical danger be-
cause of the combination of the two ?

Dr. Gearing. I can't answer the question on physical danger. The
answer from the standpoint of the patient is that many of them in
the first few months that they are on methadone maintenance do
shoot heroin and come back very angry because they spent their money
on nothing, because they get no euphoria. That is supposedly the block
of methadone, is that it blocks the effects of heroin.

Chairman Pepper. We will take a short recess at this point.

(A brief recess was taken.)

Chairman Pepper. The meeting will come to order, please.

Dr. Gearing, if I may interrupt before the other members return,
I Avould iust like to ask you three things :

One : We have had reports that about six people have died fn the
District of Columbia in the last few months from taking methadone.
Have you any comment to make on that ?

Dr. Gearing. I would defer that to Dr. DuPont in his testimony,
because he has the knowledge. I have only read it in the newspapers.

Chairman Pepper. Have you experienced deals from methadone in
New York?

Dr. Gearing. Yes.

Chairman Pepper. Roughly how many ? ^

Dr. Gearing. Aside from the ones in children, which were acci-
dentally taken thinking it was orange juice, I think that there may be
two or three in the young teenagers.

Chairman Pepper. In your experience, are the deaths generally in
cases where they were not previously addicted to heroin and they just
started right off taking methadone ?

Dr. Gearing. They were not tolerant to the dose of methadone they
were taking. Whether they were on other drugs or not, I don't know.

Chairman Pepper. Does the taking of heroin give you a tolerance for
methadone ?

Dr. Gearing. I don't know.

Chairman Pepper. Well, the deaths, you would say, are people who
have not developed tolerance for methadone ?

Dr. Gearing. That is correct.

Chairman Pepper. Who are beginning to take it for the first time ?

Dr. Gearing. Who just took it accidentally or just for kicks, just like
many of the heroin deaths we have in New York City are not in
addicted kids. They are. in kids that are shooting for the first or second
time and get either an allergic or some other kind of reaction, or a real
overdose.

Chairman Pepper. Do you agree with the testimony before this
committee of Dr. Halpern of the city of New York, that any given
dose of heroin, even to an addict, may be a fatal one ?

Dr. Gearing. I certainly wouldn't contradict Dr. Halpern in a field
in which he is an expert and I am not.

118

Chairman Pepper. Would you have any comment to make about the
District of Columbia methadone maintenance program ?

Dr. Gearing. Very few comments at the present time, because I
have just recently started working with them. I think my first com-
ment is on how rapidly it has ^rown and how well they were handling
the problem of large numbers in any single unit.

On my first visit to D.C. Hospital I was overwhelmed with the size
of their population, that they were handling with the staff that they
had and their unit at that point was, I think, something in he neighbor-
hood of 600 patients. In T^ew York City, most of the outpatient units
handle between 125 and 150 patients each.

Chairman Pepper. Do you have enough money and personnel and
facilities for the treatment of all of the heroin addicts in the city of
New York?

Dr. Gearing. Do I, sir ?

Chairman Pepper. Yes. Are there available enough facilities and
personnel ?

Dr. Gearing. I am sure the answer to that is an unqualified no. I
don't know if there is enough money in the world.

Chairman Pepper. Same situation all over the country ?

Dr. Gearing. Yes.

Chairman Pepper. One other thing. Would you state what are the
goals of the methadone maintenance program ?

Dr. Gearing. Freedom from "heroin hunger," decrease in antisocial
behavior, increase in social productivity, and recognition and willing-
ness to accept help for other problems, such as alcohol abuse, other
drugs, psychiatric and medical problems.

Chairman Pepper. Mr. Winn.

Mr. Winn. Thank you, Mr. Chairman.

Dr. Gearing, just a quick question. We heard yesterday in the testi-
mony the difference between psychotic craving and physiological crav-
ing. What is the methadone reaction to these two cravings ?

Dr. Gearing. The two psychiatrists who will follow me will probably
be able to answer that question much better than I.

It would appear from the patients who are admitted to the metha-
done maintenance program in New York City that gross psychiatric
problems are not a major portion of their problems. They have be-
havioral problems very similar to the behavior problems that some of
the rest of us have, and need sometimes more help with those and
psychiatric help is available both on an individual basis and group
psychotherapy.

But it is not universally required.

Mr. Winn. The testimony yesterday was that they could go through
all of these treatments, cold turkey and all of that, and still have a
psychiatric craving, that even though they were supposedly cured, the
psychiatric craving would drive them back to hef oin.

Dr. Gearing. I am sorry, but I don't know what a psychiatric crav-
ing is, so I can't answer your question.

Mr. Winn. But you have heard the term ?

Dr. Gearing. Yes.

Mr. Winn. Thank you very much.

Chairman Pepper. Sorry, Mr. Mann, had you finished your ques-
tioning?

119

Mr. Manx. I have one or two more, and I think perhaps I am in the
psychiatric field, too, but not in the evaluation field.

Would a nonaddict enjoy the methadone program ?

Dr. Gearing. Would a nonaddict ? I wouldn't think so.

Mr. Mann. Well, it offers a lot of other benefits, other than mere

Dr. Gearing. Not really; you have to take an awful lot of medica-
tion every day.

Mr. Mann. Could a nonaddict get into the program ?

Dr. Gearing. It would be difficult.

Mr. Mann. This again is a question I perhaps shouldn't ask.

Does the existence of a methadone program perhaps lessen the stigma
or lessen the resistance to one becoming involved in heroin in the
first place ?

Dr. Gearing. I have no idea but I would think not ; no.

Mr. Mann. You would hope not ?

Dr. Gearing. Yes.

Mr. Mann. You obviously have great faith in this program, and I
am curious as to your major reaction, based on your evaluation as to the
disadvantages, not in detail, but your major reaction to the disad-
vantages.

Dr. Gearing. The disadvantages have been well stated by many
people. The first one is that it is an addictive drug that you are sub-
stituting for another one. This is not my major objection.

The second is it is a drug that has to be taken every day. It is our
hope that at some point there will be developed a longer acting metha-
done kind of treatment.

I think the major objection to the program in New York City is
the waiting time it takes to get into it, once the patient makes the de-
cision that he wants to try it.

Mr. Mann. Thank you.

Thank you, Mr. Chairman.

Chairman Pepper. Mr. Keating?

Mr. Keating. No questions.

Chairman Pepper. Mr. Rangel ?

Mr. Rangel. Yes ; Mr. Chairman.

Doctor, a lot of support is received by the methadone proponents
because of the drastic decrease in crime. You presented, this morning,
some rather dramatic statistics, and if I understand them correctly,
you took a sampling of drug addicts and compared their records after
having gone through the methadone treatment.

Dr. Gearing. Yes; using the same sources of information we use
on patients in the program.

Mr. Rangel. And using their past criminal records as an indication
of how drastic the criminal activities were reduced.

Now, as a part of your program, I understand that you offer medical-
psychiatric-social services, educational, job training, and all of this as
a part of the methadone training program or methadone treatment
program ; is that correct ?

Dr. Gearing. Those services are all available to the patient ; yes, sir.

Mr. Rangel. Assuming that all crimes are not comitted by addicts,
that you had a group of people in central Harlem that have the same
type of criminal record, and they were offered the same type of sup-
portive services, of course, without the assistance of methadone, would

120

it not be so that we could project a drastic decrease in their criminal
activity, especially in view of the fact that many of these addicts are
former addicts employed by the programs on which they are treated?

Dr. Gearing. I would hope that that were true, and I would like
some data to show that it is true. The problem that we have had, is we
have no comparative data, that is the reason we have to force a com-
parison group. We have no data from any group that has such a
facility.

The only data we do have is in the detoxification unit. They do
have a group where they have offered the services and they have not
been terribly successful.

Mr. Rangel. Notwithstanding all of this dramatic data and de-
crease in crime, you could not really determine whether or not the
decrease was due to job training, consultant services, opportunities
for employment, or methadone?

Dr. Gearing. That is correct. What we are saying is that this pro-
gram offering this package in this way is doing this. That is all we
can say.

Mr. Rangel. Right.

Now, in answer to a previous question you were saying that it is pos-
sible for one to get a high, say, from methadone if not given orally.

Dr. Gearing. It is my understanding that methadone intravenously
gives a very nice high.

Mr. Rangel. Well, the drug which is presently being adminis-
tered in New York, could that be reduced to liquid so that it could be
given intravenously ?

Dr. Gearing. As I understand it, it is very difficult. I was goin^ to
say it can't be done, but I was told today that it can, and knowing
addicts who can shoot milk and a few things that some of the rest of
us wouldn't dream of, they probably could shoot it ; yes.

Mr. Rangel. Well, being raised in that community and still li\dng
there, there is some thought we have now developed a type of metha-
done addict, and my real question was in view of the earlier question
of dual registration or using different names, if you now believe, as I
believe, that it is possible to be produced as to what is dispensed to a
drug that can be injected into the body intravenously, then what is to
prevent a community from becoming addicted to methadone as a first
experience in view of the fact that the patient could give any name
and give a different name and receive free drugs?

Dr. Gearing. I think this goes back to my suggestion that the dis-
pensing of the drug is the key issue in this whole problem.

Mr. Rangel. My question was one of registration. As I understood
earlier

Dr. Gearing. The patients do not get a week's supply of medication
to sell on the street. The patient gets one dose that he takes on the
premises.

Mr. Rangel. What about the patients that you were saying come
in twice a week?

Dr. Gearing. Well, those patients are not the source of the drugs
on the street. Those are the patients who have been in the program for
a good long time. They are not selling it.

Mr. Rangel. What I am asking is : Is it possible for this patient to

121

go to two or three different clinics and use two or three different names
and receive two or three weekly dosages ?

Dr. Gearing. If he went to a different place he would have to start
all over again, because he would have to register as a new patient.

Mr. Brasco. Would you yield for one moment?

Mr. Rangel. Yes.

Mr. Brasco. Dr. Gearing, I have heard, as Congressman Rangel has
been trying to point out, that there is some traffic in the street with
methadone, but what would be the value ? This is something that es-
capes me. Why take the methadone if you don't get the euphoric effect
that you want ? Is there some other valiie ?

Dr. Gearing. These are questions that I cannot answer. This is not
my field. I know that there is methadone on the street, and I think I
told you where we believe the major source of it comes from. In fact, it
was highlighted in the Xew York Times the other day. I do not think
that the majority of methadone on the street comes from the patients
who are on methadone maintenance. This is a very valuable piece of
equipment to the patients.

Mr. Brasco. But you don't know, then, I take it, the answer to my
question. "Whether or not the use of methadone is the initial attraction
as the use of heroin would be to an individual ?

Dr. Gearing. I wish you would save those questions for Dr. Jaffe.

Mr. Brasco. Thank you.

Mr. Rangel. My last question is do you know of any reason why the
Food and Drug Administration has not certified this drug?

Dr. Gearing. I think they are overly cautious, to put it mildly.

Chairman Pepper. Any other questions ?

Thank you very much, Dr. Gearing. We appreciate your valuable
testimony this morning.

(The following material, previously referred to, was received for
the record:)

[Exhibit No. 10(a)]

Successes and Failures in Methadone Maintenance Treatment of Heroin

Addiction in New York City

(By Frances Rowe Gearing, M.D., M.P.H. (Supported under Contract No. C-
35806 from New York State Narcotic Addiction Control Commission), Associ-
ate Professor, Division of Epidemiology Columbia University School for Public
Health and Administrative Medicine, and Director, Methadone Maintenance
Evaluation Unit)

For Presentation at Third National Conference on Methadone Treatment, Satur-
day, November 14, 1970, Park Sheraton Hotel, New York, N.Y.

introduction

October 1 marks the fifth anniversary of the establishment of the methadone
maintenance evaluation unit and the first meeting of the evaluation committee.
When our unit began operations there were 66 men and eight women in the pro-
gram and there were facilities available to admit approximately seven new
patients each month. As time has marched on, the progress reports from our
Evaluation Unit have attempted to monitor the progress of the program with
cautious optimism, with the result that we have been quoted and misquoted by
legislators at all levels of government and by all the mass media.

Our recommendation for continued expansion of the program has resulted in
a veritable population explosion in the past year. As of October 31, 1969, the
methadone maintenance treatment programs under our surveillance included
six inpatient induction units, and ambulatory induction was just beginning. The

60-296 O— 71— pt. 1 9

122

admission rate was approximately 50 patients each month, equally divided be-
tween ambulatory and inpatient induction with rather cautious selection of those
admitted for ambulatory induction.

This year has seen an almost complete reversal in this procedure. The vast
majority of patients are currently being stabilized on an ambulatory basis, and
inpatient services are used only for those patients who present unusual problems.

As of October 31, 1970, we have under surveillance 13 inpatient induction units
and 46 active outpatient and ambulatory units. These units cover the four largest
New York City boroughs and lower Westchester County. How many patients
are involved? Table 1 shows the October 31, 1970, census. There have been 4,376
admissions to date, and 3,485 patients are under treatment. This is contrasted
with the census as of October 31, 1969, when there were 2,325 admissions and
1,886 patients in treatment. This highlights the rapid expansion from approxi-
mately 50 patients per month to a level of 50 new patients each week. The loca-
tions of the inpatient and outpatient units are listed in appendixes A and B for
those who are interested. The rapid induction group is a relatively new unit,
opened in late July 1970, to which a group of approximately 100 patients from
the waiting list have been offered ambulatory induction to methadone main-
tenance with medication only and little or no supportive services at the outset.
The success rate in this group is being followed with great interest because Its
initial objective is to delineate that portion of the accepted patients which can
be maintained with only minimal supportive services.

DESCRIPTION OF SAMPLE

The age distribution of patients in the methadone maintenance treatment pro-
gram has not changed substantially over the past 5 years despite the change in
age criteria for admission. This appears to be the result of two balancing forces.
These are (1) the inclusion of a few 18-year-old patients, and (2) the admission
of a small number of oriental patients who are in their late 50's. Therefore, the
median age of all patients remains at about 33.3 years with the average age of
the black patients somewhat older (35.6) .

The ethnic distribution remains approximately 40 percent white, 40 percent
black, 19 percent Spanish and 1 percent oriental.

We will discuss the "failures" first.

RATE OF DISCHARGE

The rate of discharge by month of observation has demained amazingly stable
despite the changes in admission criteria and the change of emphasis from in-
patient induction to ambulatory induction. This is illustrated in figure 1 where
the rates of discharge for the two groups are contrasted. The two curves are
identical. The Van Etten group, which active tuberculosis as an additional prob-
lem to heroin addiction, demonstrate a somewhat accelerated discharge rate as
might be expected.

In figure 2 we contrast three cohorts of 500 patients by date of admission, and
once again we find no difference in rates of discharge among these three cohorts
representing the first 1,500 patients admitted to the program.

Figure 3 contrasts the discharge rate for men and women. The slight difference
shown is not significant due to the much smaller number of women. The rate of
discharge for men by age at time of admission is shown in figure 4 and once
again shows no difference between younger and older patients. A small difference
appears in figure 5 between the rate of discharge in the third year between
black and white patients. This difference is not statistically significant at this
point but bears monitoring in the future.

SEASONS FOR DISCHARGE

As shown in figure 6 problems with alcohol abuse as a reason for discharge
increases with age at time of admission for both men and women, drug abuse
(primarily amphetamines and barbiturates) as a reason for discharge decreases
with age and is more common among the women than among the men. Voluntary
withdrawal from the program increases with age particularly among the men.

Discharge for behavior or psychiatric reasons is more common among the
younger patients of both sexes. Deaths follow the pattern in the general
population.

123

When we look at reasons for discharge by ethnic group as shown in figure 7,
we note that alcohol problems are more common among the black patients and
drug abuse is more commonly a factor among the white and Spanish patients.

Voluntary withdrawals and discharge for behavioral reasons account for the
majority of dropouts in the first year. Chronic problems with alcohol abuse, and
continued drug abuse were the major causes of discharge in the second and third
year.

FOLLOWUP OF DISCHARGED PATIENTS

With the assistance of two medical students, (Michael Lane, Downstate Medi-
cal School, and Mary Hartshorn, Medical College of Pennsylvania) during this
past summer, we completed an intensive foUowup on a sample of patients who
had left the program. We selected all patients who were discharged alive by
December 31, 1969, and who had been in the program 3 months or longer at the
time of discharge. This gave us a pool of 562 persons. We divided this group into
two segments: (1) those who had left the program voluntarily, and (2) those
who had been discharged from the program for cause.

Our primary source of followup was the New City Narcotics Register which
receives reports from the police and correction agencies, hospitals, and treat-
ment programs, and from private practitioners. Another very useful source was
a series of interviews with patients who left the program and have subsequently
been readmitted. This was a major contribution by the medical students.

For the sample of 281 patients on whom we could obtain 6 months of follow-
up the results are shown in table 2.

Those patients who left the program voluntarily had a lower arrest and de-
toxification record, than the rest. They also had a larger proportion admitted
to other treatment programs an one-third had been readmitted to the program,
contrasted with only 6 percent of those discharged for cause. If one considers
that no record found is roughly equivalent to remaining "clean," one-third of
this group were still "clean" 6 months after leaving the program.

The same sampling procedure was followed for the 396 patients on whom we
could obtain 12 months to followup. These results are shown in table 3. In this
group only 21 percent would be considered still "clean." The readmission rate
was somewhat lower (13 percent). Except for arrests and deaths those who left
the program voluntarily are very similar to the other group.

Table 4 shows the results of the followup on our sample of 181 patients on
which we had a followup of 1 year or more. Here the readmission rate is 22
percent and the proportion who appear to have remained "clean" is only 18
percent and the death rate reaches 5 percent.

These data would tend to indicate that, among those patients who withdraw
from methadone maintenance treatment, only a small portion have been able to
"make it" on their own.

Because of the tremendous current interest in "criminality" associated with
addicition, we looked into the previous arrest records of those patients who
have remained in the program, contrasted with those who left the program
voluntarily, and those who were discharged for cause. We contrasted this, in a
"before and after" picture, as shown in figure 3. It is interesting to note that
the past history of those who were discharged for cause with reference to arrests
is worse than either of the other two groups — and that their behavior following
discharge is as poor or worse than before admission. Those who left voluntarily,
demonstrate a short preiod of improvement but also tend to return to their
previous arrest pattern. Those who remained in the program show a constant
and accelei'ated decline in criminal behavior as measured by arrests.
Enough of failures. Now let's discuss successes.

CRITERIA FOR SUCCESS

The criteria established by our evaluation unit with the approval of the evalua-
tion committee for measuring success of the program has resolved around four
basic measures :

(1) Freedom from heroin "hunger" as measured by repeated, periodic "clean"
urine specimens.

(2) Decrease in antisocial behavior as measured by arrest and/or incarcera-
tion (jail).

(3) Increase in social productivity as measured by employment and/or school-
ing or vocational training.

(4) Recognition of, and willingness to accept help for excessive use of alcohol,
other drugs, or for psychiatric problems.

124

BESULTS

(1) Although many of the patients test the methadone "blockade" of heroin
one or more times in the first few months, less than 1 percent have returned
to regular heroin usage while under methadone maintenance treatment.

(2) Antisocial behavior as measured by arrests and incarcerations (jail) have
been looked at in several ways. First, the percentage of arrests among patients
in the program during the 3 years prior to admission was compared with the per-
centage of arrests of these same persons following admission. This "before and
after" picture is also contrasted with the proportion of arrests in a contrast group
of 100 men selected from the detoxification unit at Morris Bernstein Institute
matched by age and ethnic group and followed in the same manner. The results
are illustrated in figure 9. The arrest records of these two groups are quite simi-
lar for each year of observation prior to admission. Following admission to the
program, the contrast is striking for each period of observation with the metha-
done maintenance patients showing a marked decrease in the percentage of
patients arrested, and the contrast group showing a pattern very similar to the
earlier period of observation.

We have also calculated the arrests per 100 patient-years of observation for the
3 years prior to admission in contrast to the arrests per 100 patient-years of
observation after admission. We have compared these data using the same com-
putations for the contrast group. The results are shown in table 5. These results
would appear to indicate that remaining in the methadone maintenance program
does indeed decrease antisocial behavior as measured by arrests or incarcerations.

(3) Increased social productivity can best be illustrated by the employment
profiles shown in figures 10 and 11. There is a steady and rather marked increase
ii the employment rate with a corresponding decrease in the percentage of
patients on welfare as time in the program increases. This is true both for the
men and the women. These data include both ambulatory and inpatient induc-
tion groups. This accounts for the increased percentage of men employed at time
of admission since this was one of the early criteria for admission to an ambula-
tory unit.

(4) Figure 12^ is an attempt to illustrate stability of employment among
patients remaining in the program as contrasted with their previous employment
experience. The shaded area might be considered as a measure of their increased
social productivity since admission to the program.

(5) Although chronic alcohol abuse continues to be a problem for approxi-
mately 8 percent of the patients (both men and women), and for some becomes
the principal reason for discharge, a majority of these patients show continued
improvement in their ability to handle their alcohol problem with the support
and assistance of members of the program staff who recognize the problem, and,
are willing and able to cope with it.

(6) Problems with chronic abuse of drugs such as barbiturates, amphetamines,
and more recently cocaine are evident in approximately 10 percent of the patients.
There again, for some, it has resulted in discharge from the program. For many
othets, the patients are able to function satisfactorily, with the assistance and
support of members of the program staff.

CONCLUSIONS

On balance, the successes in the methadone maintenance treatment program
far outweigh the failures. The rapid expansion of the program during the past
year, and the change in emphasis to include primarily ambulatory induction
under the expanded admission criteria does not appear to have made any notice-
able change in the effectiveness of this treatment for those heroin addicts who
have been accepted into the program. A majority of the patients have completed
their schooling or increased their skills and have become self-supporting. Their
pattern of arrests has decreased substantially. This is in sharp contrast to their
own previous experience, as well as their current experience when compared with
a matched group from the Detoxification unit, or when compared with those
patients who have left the program. Less than 1 percent of the patients who
have remained in the program have reverted to regular heroin use.

A small proportion of the patients (10 percent) persent continued evidence of
drug abuse involving use of amphetamines, barbituarates, and cocaine, and
another 8 percent demonstrate continued problems from chronic alcohol abuse.
These two problems account for the majority of failures in rehabilitatin after the
first 6 months.

125

Methadone maintenance as a treatment modality was never conceived as a
"magic bullet" that would resolve all the problems of patients addicted to heroin.
For this reason, we believe that any treatment program using methadone mainte-
nance must be prepared to provide a broad variety of supportive services to
deal with problems including mixed drug abuse, chronic alcoholism, psychiatric
or behavioral problems, and a variety of social and medical problems.

Many questions continue to remain unanswered with reference to the role of
methadone maintenance in the attack on the total problem of heroin addiction ;
nevertheless the data presented on the group of patients who have been ad-
mitted to this methadone maintenance treatment program continues to demon-
strate that this program has been successful in the vast majority of its patients.

After a careful review of the data related to successes and failures over the
past 5 years, the methadone maintenance evaluation conmiittee has submitted
the following recommendations as of Friday, November 6, 1970 :

KECOMMENDATIONS

As a result of the continued encouraging results in the methadone maintenance
treatment program through October 31, 1970, the methadone maintenance evalu-
ation committee recommends :

(1) That there be continued financial support for the methadone mainten-
ance treatment program to allow continued intake of new patients using ad-
mission criteria including a minimum age of 18 years and a history of a mini-
mum of 2 years of addiction with care in selection of patients to prevent the
possibility of addicting an individual to methadone who is not physiologically
addicted to heroin.

(2) That there be continued evaluation of the long-term effectiveness of the
methadone maintenance treatment program for the group stabilized on art in-
patient basis, the group being stabilized on an ambulatory basis, and the group
undergoing rapid induction.

(3) That new programs which plan to use methadone maintenance should in-
clude all eleemnts of the program including :

(c) Availability of adequate facilities for the collection of urine and labor-
atory facilities for frequent and accurate urine testing.

(&) Medical and phychiatric supervision.

id) Adequate staff including vocational, social, and educational support
and counseling.

(e) Rigid control of methods of dispensing methadone and number and
size of aoses given for self -administration in order to prevent diversion to
illicit sale or possible intravenous use.

(/) Staff members of potential new programs planning to use methadone
maintenance be trained in this technique in a medical center which has
been shown to use methadone maintenance effectively.
4. That continued research is essential particularly with reference to :

(&) Developing programs using methadone maintenance in combination
with other approaches to the treatment of heroin addiction.
Projects in these areas should be supported and encouraged, but must be con-
sidered new research studies, and should be subjected to the same surveillance,
and independent evaluation as the current programs.

(5) That methadone maintenance not be considered at this time as a method
of treatment suitable for use by the private medical practitioner in his office
practice, because of the requirements for other program components including
social rehabilitation and vocational guidance.

(6) That a pilot or demonstration project be developed involving the use of
properly trained practicing phy.sicians as an extension of an organized methadone
maintenance treatment program to treat those patients whose needs for ancillary
services are minimal. These patients should be continued under the supervision
of the methadone maintenance treatment program for periodic evaluation and
urine testing.

ACKNOWLEDGMENTS

1. The members of the methadone maintenance evaluation committee, both past
and present with particular reference to Dr. Henry Brill, who has so aptly
chaired that committee since its inception.

126

2. All the members of the methadone maintenance treatment program staff for
their devotion to their job and for their cooperation whenever needed.

3. The staff of the Rockefeller Data Bank especially Dr. Alan Warner and
Mrs. Ellen Smith for their willingness to make available to us, whenever re-
quested, data which has been a crucial starting point of our evaluation.

4. Those medical students who have made substantial contributions to our
efforts over the past 4 years.

5. The directors of the New York City Narcotics Register who have allowed
us to use their data for validation and for followup. These listed in chronological
order over the past 5 years are : Dr. Florence Kavaler, Mrs. Zili Amsel, Miss Joy
Fishman, Mr. Sherman Patrick.

6. The diligence and devotion of my staff including : Mrs. Dina D'Amico, Mrs.
Angela del Campo. Mrs. Frieda Karen, Miss Elaine Keane, Mrs. Dorothy Mad-
den, Mrs. Ingel Mayer.

7. And last but not least to the New York State Narcotic Addiction Control
Commission for funding our efforts.

127

►-

o
O

,^_

•ESS

^ TO---

E £<^

Q-o

i: »^

CNj^tOm

a? c

CM 'O- ID eg

^ o

Cs4^^^

E«

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-Q o

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Figure 1

1.0 -

30-

20-

10-

11/10/70

128

HETHADOHE MAINTENANCE TREATMENT PROGRAM

Rate of Discharge by Month for Patients Inducted on an Ambulatory Basis

Versus In-Patient Induction and Van Etten

as of June 50, 1170

n= 1921

n= 130'i o-
n= 11)7 X-

— - In-Patlent Induction
-O = Ambulatory
-X» Van Etten

—r

— r

— r
33

Months

— r
39

Figure 2

Methadone Maintenance Treatment Program

Rate of Discharge by Month for Three Successive Cohorts of 500 Patients
By Dote of Admission

Cohort #1 = • '

Cohort #2 -

Cohort #3 = X X

n/K/70

—r

-r~

"T"

12 15 18

21 2k 27 30 33 36 39 1(2 1*5

Months

129

Figure 3

METHADONE MAINTENANCE TREATHEIIT PROGRAM

Rate of Discharge by Month for Men versus Vtonen
as of June 30, 1970

100-
90 i
SO
70

50-

llO-
30-

20-

n/ic/70

~~o~r

~o^r-

^=r-

--o^^r^

-o—

-o~-

— r-
15

— 1-
18

2i 21' 27 30 33 36

Months

O o-

Men n= 2835

Women n= 537

Figure ^i

60-1

so-
li 0-

30-

20-

10-

Methadone Maintenance Treatment Program

Rate of Discharge by Hcnth for 2835 Men by Ag? at Time of Admission
as of June 30, 1970

— r-
12

. .= -^30Yrs. n= 709

•= 30-39 Yrs.n= 1802

> v= I10+ Yrs. n= 32'i

— I 1 1

15 18 21

Months

zif 27

— r-
30

— I
36

11/18/70

Figure 5

100-
SO-
SO-

70-
60-

50 •
o

130

Methadone Halnten?nce Treatment Program

Rate of Discharge by Month for ?306 Men by Ethnic Group
as of June JO, 1970

11/' 0/70

. ■= White n=l IJO

X v= Spanish n= SS^

= Black n=I122

0 3 6 9

"1 1 1 1 1 1 1 1 1 1

12 15 18 21 2i) 27 30 33 36

Months

Figure 6 METHADOflE MAIMTEMANCE TREATMENT PROGRAM .

Percentage Distribution of Principal Reason for Discharge of 718 Patients by Age at Time of Admission

<lO

c 20

-Ti

f
i

Alcohol

20 -

A) Women n=l 19

■

Arrests Drugs Voluntary ''ehavior

Death

[;f: :JAge 20-29

B) Men n=599 |_l*9e 30-39

K/ylAge 110+

JZZZL

E^m

Alcohol Arrests

Drugs Voluntary Tehavior

Death

11/10/70

131

Figure 7 METHADONE HAINTEHAHCE TREATMENT PROGRAM

Percentacje Distribution of Principal "eason for discharge of 710 Patients by Ethnic Group

"lO-

c 20-

r-^

A) Women n= 1 19

Alcohol Arrests Drugs Voluntary "ehavior Death

Jia

20-

B) Men n= 599

Black

V/hite

Spanish

Alcohol Arrests Drugs Voluntary Behavior

Death

11/10/70

132

TABLE 2.-METHAD0NE MAINTENANCE TREATMENT PROGRAM
IFollowup of 281 patients 6 months following discharge from M.M.T.P.; in percent]

Left

volun-
tarily

Dis-
charged
for cause

Total
dis-
charge

Left

volun-
tarily

Dis-
charged
for cause

Total
dis-
charge

Arrest or jail

Dead

Detoxification

Other Rx program

Medical or psychiatric
facility .

26
2

20
4

3
2

2
2

Moved

Readmitted

No reports found

Total sample

Total N..

33
22

11
33

. 45/100
. 90

236/100
472

281/100
562

Private medical doctor. .

TABLE 3.— METHADONE MAINTENANCE TREATMENT PROGRAM
IFollowup of 198 patients up to 1 year after discharge from M.M.T.P.; in percent]

Left
volun-
tarily

Dis-
charged
for cause

Total
dis-
charge

Left
volun-
tarily

Dis-
charged
for cause

Total
dis-
charge

Arrester jail

Dead

Detoxification

Other Rx program

Medical or psychiatric

facility

Private M D

34"

3
3

28
2

23
6

25
2

25
6

4
2

Moved

Readmitted

No reports found

Total sample

Total N

2
13
21

. 32/100
. 64

166/100
232

198/100
396

TABLE 4.-METHAD0NE MAINTENANCE TREATMENT PROGRAM
[Followup of 181 patients 1 year or more after discharge from M.M.T.P.; in percent]

Arrest or jail.

Dead

Detoxification

Other Rx program

Medical or psychiatric

facility..

Private M.D..

Left Dis-

volun- charged

tarily for cause

37
11

6
6

30
5

27
11

7
3

Total

dis-
charge

28
5

28
22

7
3

Left Dis-

volun- charged

tarily for cause

No reports found.
Readmitted'

21
129

17
121

Total sample 28/100 153/100

Total N 56 306

Total
dis-
charge

18
122

181/100
362

> Readmitted patients each had 1 or more reports of arrest or detoxification.

Figure 8

133

HETHAOOIIE MArMTCMArXE JREMIW.'T PROGRAM

Comparison of Arrest Records Amonn Persons
Continuing and Oischarcerl from Methadone Maintenance Treatment Program

Prior to Admission

a - Since Admission
■^ b £ c - Since Discharge*

years

' years ^

n ".MP , (2560) (2560)
n Vol.Dis. CtS) CtS)
n lnvol.Dis.(23f>) (23&)

(2560) (2560) OSA'.) (788) iiBt*)
('•5) (AS) (32) (20
(236) (236) (166) (153)

*AI1 discharges had participated in HMTP for at least 90 days prior to discharge.
10/26/70

Figure 9

134

Methadone tlaintenance Treatment Progran

Percentage Distribution of Arrests for 2G'»1 Men In Methadone Maintenance Program

Three Months or Longer as of Harch 31, K-?") and Contrast Group

5y Months of Observation

DEFORE <-

START

^ AFTER

Percentage
30-1

20-

10-

Year Prior to Admission
to Program

Year After Admission
to Program

n MMP (28'il)

(23'il)

(28'»J)

(281)1)

(15'*'.)

(788)

OSM

n Contrast (100)

(100)

(98)

(95)

(92)

11/10/7^

135

TABLE 5.— METHADONE MAINTENANCE TREATMENT PROGRAM

iThe Number of Arrests and Incarcerations per 100 Person-Years for Methadone Maintenance Patients Before and After
Admission Contrasted With Patients From Detoxiflcation Unit]

Methadone Detoxification
group group

Before admission:

Arrestsper 100 person-years 115 131

Jail per 100 person-years... 49 52

N=person-years 17,500 600

Following admission:

Arrestsper 100 person-years 4.3 135

Jail per 100 person-years 1.0 63

N=person-years 10,800 1,040

136

Figure 10

Methadone Ka'ntanance Treatmf:nt Program

EfTipIoyment Status and School Attendance for Men in Metiadone Maintenance

Three Months or Longer as of March 3'. '970

(In-Patient and Ambulatory Induction

00- ^

— 1

80-

^32

—

^ —

—

/ y

[ '

60 - /

• y/^

/ /

"tO -11

20 _
0 -

•

School
Welfare

Supported by
Others

Employed

6 Months 12 Months 18 Months Ih Months 30 Months 36 Months 'i2 Months A8 Months
Months Following Admission to Program
n- (I97lt) (1807) (1330) (891) (650) (468) (330) (203) (R1)

11/9/70

Figure II

Methadone Haintensnce Treatmant Program

Employment Status and School Attendance for '(66 Women in Methadone Maintenance
Three Months or Longer as of 'l.-.rch ?1, WT^
(In-Patlent and Ambulatory Induction)

100

11/10/70

n= (1)66)

VsM School

Welfare

Homemsker

Employed

6 Months 12 Months 18 Months 2't Months 30 Months 36 Months
Months Following Admission to Program
(JitS) (2i.5) (161) (109) (71) (A5)

137

Figure 12 Methadone Maintenance Treatment Program

Percent of Pcrson-fonths of Observation During Which Mon in Program l/ere Employed
Defore and After Admission by Duration of Employment
as of July 31, '963

Increase of Observed
Over Expected

* F 1 A Person-Months of Employment

* Einployed = Person-Months of Observation

Sli Months
'/] 51 Months

% Employed
Prior to Admission

% Employed
Following Admission

ADMISSION TO PROGRAM

11/10/70

60-296 O - 71 - pt. 1 - 10

138

Appendix A^ — Methadone Maintenance Treatment Program
Inpatient Induction Units by County as of October 31, 1970

Manhattan :

Grade Square Hospital (men and women).

Harlem Hospital (men).

Morris J. Bernstein Institute (men ad women).

Riker's Island (men).

Rockefeller University Hospital (men and women).

Roosevelt Hospital (men and women).

St. Luke's Hospital (men and women).
Bronx :

Albert Einstein Medical Center ( men and women ) .

Bronx State Hospital (men and women) .
Brooklyn : Brookdale Hospital (men and women).
Westchester County :

St. Joseph's Hospital (men and women).

White Plains Hospital (men and women).

Yonker General Hospital (men and women).

Appendix B — Methadone Maintenance Treatment Program
Outpatient and ambulatory induction units by county as of October 31, 1970

Number
of units
Manhattan :

City Probation 2

Gracie Square Hospital 1

Greenwich House 1

Harlem Hospital 5

Jewish Memorial Hospital 1

Morris J. Bernstein Institute 1

Lower East Side 10

Lower West Side 2

Rapid Induction 1

Mount Sinai Hospital 1

Rockefeller University

Hospital 2

Roosevelt Hospital 1

St. Luke's Hospital-
St. Vincent's Hospital.
Bronx :

Bronx State HospitaL.

Lincoln Hospital

Van Etten Hospital—

1
1

1
1
1

Number
of units
Brooklyn :

Brookdale Medical Center 1

Coney Island Hospital 2

Cumberland Hospital 2

Lutheran Hospital 1

Methodist Hospital 1

Queens :

Long Beach Memorial

Hospital

Triboro Hospital

Westchester :

St. Joseph's Hospital 1

White Plains Hospital

Yonkers General Hospital

Yonkers Public Health Build-
ing (WCCMHB)

1
2

1
1

[Exhibit No. 10(b)]
Position Papek : Methadone: — A Valid Treatment Technique

(By Frances Rowe Gearing, M.D., M.P.H. (Supported under Contract No. C-35806
from New York State Narcotic Addiction Control Commission), Associate
Professor, Division of Epidemiology, Columbia University School of Public
Health and Administrative Medicine, and Director, Methadone Maintenance
Evaluation Unit)

For Presentation at State Conference on "Drugs — The Issues on Trial,"
Pontiac, Mich., December 2, 1970

Position Paper — Methadone Maintenance : a Valid Treatment for

Heroin Addiction?

My answer to this question is yes when properly administered in an organized
methadone maintenance treatment program.
There are at least five basic reasons for my positive response which I list:

139

1. DRUG PKOPEKTIES

Methadone has several properties which make it useful as a treatment for
heroin addicts. These properties includes the following :

(a) It is a longer acting drug than heroin. Patients on methadone mainten-
ance, after a relatively short induction period, require only one dose a day. This
contrasts with four to six fixes a day for the patient "hooked" on heroin.

(&) Methadone is given by mouth in noninjectable form. This alone makes it
most attractive from a medical standpoint, because it is well-known that many
of the medical problems of heroin addicts are related to intravenous injection
without proper sterilization techniques. These problems include, hepatitis, endo-
carditis, tetanus, and a plethora of other medical problems.

(o) Patients on methadone can be gradually built up to a stabilizing dose of
between 80-120 mgs. daily, and can be maintained at this level over periods of
time up to 5 years without having to alter the dosage level. This is in sharp
contrast to the addict's experience with heroin. Patients on heroin rapidly de-
velop a tolerance to the ordinary street "bag" to the point where they have
eitlier to increase the number of bags for each "fix" and increase their hustling
in order to get more "bags" more often to support their needs, or to apply at a
detoxification unit for a drying-out period which will bring them back on the
street within 2 weeks with a less-expensive habit.

(d) Methadone maintenance when used at high dosage levels produces a
"blockade" against the effect of heroin which might be referred to as heroin
"euphoria." Under carefully controlled circumstances, patients stabilized on
methadone maintenance given by mouth have demonstrated that this blockage
is effective even with high doses of pure heroin.

(e) The long-term medical effects of methadone maintenance are minimal.
This statement is based on a careful medical followup of a series of 80 patients
who have been on 80-120 mgs. of methadone daily for a period of over 5 years.

These properties make methadone a very useful tool in the treatment and
rehabilitation of patients addicted to heroin for the basic reason that it gives
former heroin users a chance to use their time in a more productive way. Under
methadone maintenance they are relieved of the problem of spending most of
their waking hours in hustling for means to get their next "fix." This difference
might be equated with the difference between the old insulin treatment for di-
abetes patients which involved three to four injections per day based on urnie
samples. The new look in diabetes treatment is more apt to be one injection a day
of long acting insulin or control by medication which can be administered orally.

2. REHABILITATION — EMPLOYMENT AND SCHOOLING

Patients on methadone maintenance can remain in their local community with
their family or peer groups throughout their treatment. They are encouraged
and offered considerable assistance by members of the program staff to complete
their basic education at least through high school, to acquire a skill through
additional vocational training, to becoming a wage earner and hopefully become
self-supporting.

These objectives have been achieved in a majority of the patients in the metha-
done maintenance treatment program in New York City as illustrated by the
employment profiles by men and women in figures 1 and 2. There is a steady and
rather marked increase in the employment rate with a corresponding decrease
in the percentage of patients on welfare as time in the program increases. This
is true both for the men and the women.

3. CRIMINALITY

Patients on methadone maintenance have demonstrated a rather striking
change in their antisocial behavior as measured by arrests as shown in figure 3,
where the percentage of arrests among patients in the methadone maintenance
treatment program is contrasted with their arrest experience for the 3 years
prior to adminission and this "before and after" picture is contrasted with the
proportion of arrests in a contrast group of men selected from the detoxification
unit at Morris Bernstein Institute matched by age and ethnic group and followed
over the same period. The arrest records of the two groups are quite similar for
each year of observation prior to admission. FoUwing admission to the program
the contrast is vivid for each period of observation with the methadone mainte-

140

nance treatment patients showing a constant and accelerated decline in criminal
behavior and the contrast group showing a pattern very similar to the earlier
period of observation.

4. SUPPORTIVE SERVICES

Patients on methadone maintenance have available to them on demand one
or more members of the program staff who are ready, willing, and able to re-
spond to their needs whether these needs be medical, psychiatric, vocational,
social, or legal.

5. PROGRAM PHILOSOPHY

Treatment programs for heroin addiction using methadone maintenance have
accepted the fact that the "hard-core" addicts have a chronic disease, and, there-
fore, need medication and support over a long period of time, if not for life.

This philosophy has resulted in a more permissive attitude toward patients
who show evidence of recurrent abuse of other drugs such as barbiturates and
amphetamines or continued chronic alcohol abuse, and every effort is made to
assist the patients in handling these problems. Only when this support fails are
patients dropped from the program.

CONCLUSION

Methadone maintenance is a valid treatment for those hard-core addicts who
are 18 years or older with a history of at least 2 years of addiction and who
have had difficulties in adjusting to the stringencies of abstinence programs.
Among patients selected in this manner methadone maintenance has proved
successful in 80 percent of more than 4,000 patients in the New York City metha-
done maintenance treatment program. A majority of the patients have com-
pleted their schooling or increased their skills and have become self-supporting.
Their pattern of arrests has decreased substantially. This is in sharp contrast
to their own previous experience, as well as their current experience when com-
pared with a matched group from the detoxification unit, or when compared with
those patients who have left the program. Less than 1 percent of the patients
who have remained in the program have reverted to regular heroin use. No other
treatment program can demonstrate a better rate of success.

Methadone maintenance as a treatment modality was never conceived as a
"magic bullet" that would resolve all the problems involved in heroin addic-
tion. For this reason, we believe that any treatment program using methadone
maintenance must be prepared to provide a variety of supportive services to deal
with such problems as mixed drug abuse, chronic alcoholism, as well as psychia-
tric or behavioral problems and a variety of other social and medical problems.
Therefore, methadone maintenance should not be considered as a method of
treatment suitable for use by the private medical practitioner in his office prac-
tice, because of the requirements for other program components including social
rehabilitation and vocational guidance.

141

Figure I

Methadone Maintenance Treatment Program

Employnent Status and School Attendance for 15-:6 i-ien in Methadone Maintenance
Three Months or Lcnqer as of March 31. 1*^70
(In-Patient Induction)

100—

80-

fo-

20-

v\-

, ^

s^^

>^:;l ^

ii^

;nV

Welfare

Employed

n= (13i6)

C .or.ths 12 Monfis 18 Months i'4 Mcr.ths 30 Months 35 Months hi Months U% Months
Month: Fcllowing Adrnission to Program
.-23) (•.;7J) (77M (606) (IjSA) (330) (203) (31)

\'in(>na

Figure 2

Methadone Maintenance Treatment Program

Employment Status and School Attendance for ^S6 Vtomen in Methadone Maintenance
Three Months or Longer as of ''arch '1, l-'?"
(In-Patient and Ambulatory Induction)

100—

11/10/70

(':!i£)

'vTsi School

V/el fare

Homemaker

Employed

6 Months 12 Months 18 Month; Ik Months 30 Months 36 Months
Months Following Admission to Program
(3^5) (2^5) (161) (10?) (71) Ct?)

142

Figure 3

•lethadone Kaintenance Treatment Program

Percentage Distribution of Arrests for 2u'»I '';en in Methadone f'aintenance Program

Three Months or Longer as of 'jrch 31, ''7"^ arid Contrast Group

^y Mor.ths of Observation

CEFORE <-

START

-^ AFTER

Percentage

3r-i

20-

10-

Year Prior to Admission
to Program

Year After Admission
to Program

n (IMP (ZSkl)

(2341)

(2841)

(1544)

(780)

(384)

n Contrast (100)

(100)

(98)

(95)

(92)

11/10/70

143

Chairman Pepper. Our next witness is Dr. Robert L. DuPont, Di-
rector of the District of Columbia Narcotics Treatment Administra-
tion since its creation in February 1970.

Dr. DuPont, a young man with impressive credentials in medicine
and phychiatry, has been changed with implementing Mayor Wash-
ington's pledge to have treatment available to every heroin addict in
the District of Columbia within 3 years.

Prior to assuming his present position, Dr. DuPont was Associate
Director for Community Services in the D.C. Department of
Corrections.

In that capacity, Dr. DuPont participated in the preparation of a
report that revealed that some 45 percent of all men brought to the
District of Columbia jail in August 1969, were heroin addicts.

Since then. Dr. DuPont has used the word "epidemic" to describe
heroin addiction in the District.

Dr. DuPont is a graduate of Emory College in Atlanta and the
Harvard University Medical School. He served his medical internship
at the Cleveland Metropolitan General Hospital and his residency in
psychiatry at the Massachusetts Mental Health Center, Harvard
University.

For 2 years, Dr. DuPont served in research and clinical psychiatry
at the National Institute of Mental Health.

Dr. DuPont, we are glad to have you again before this committee.

STATEMENT OF DR. ROBERT L. DUPONT, DIRECTOR, DISTRICT OF
COLUMBIA NARCOTICS TREATMENT ADMINISTRATION

Dr. DuPont. Thank you, Mr. Chairman.

Chairman Pepper. Mr. Perito, would you inquire?

Mr. Perito. Dr. DuPont, as you know, this committee is particularly
interested in an evaluation of methadone and related drug abuse pro-
grams. One of the matters of particular interest to the committee is
the question of the efficacy of methadone maintenance and its relation-
ship to the decrease in crime rate or illegal activity of those addicts
under such treatment. Have you any statistical studies which reflect
findings similar to those which Dr. Gearing presented to the commit-
tee this morning ?

Dr. DuPoNT. Yes, Mr. Perito. First of all, the District's program
is not simply a methadone program. It is a multimodality program in
which some people are taking methadone and some are not. Some
patients receive methadone maintenance ; others are taking it for de-
toxification.

I will answer your question, but I want to begin with that qualifica-
tion because it relates to some of the statistics that I want to bring up.

Mr. Perito. Can you tell us how many addicts are presently being
treated in your program ?

Dr. DuPoNT. The current number is 3,106 as of last Friday, and of
that number 1,760 are on methadone maintenance, 633 methadone de-
toxification, 631 are in abstinence programs. An additional 82 are re-
ceiving methadone on what we call "methadone hold" which means
emerqfency treatment prior to complete evaluation.

Chairman Pepper. How many on methadone ?

144

Dr. DuPoNT. 1,760 on methadone maintenance, 633 on methadone
detoxification, 82 on methadone hold, which is an emergency short-
term treatment, and 631 are in abstinence programs, that is, receiving
no methadone.

Mr. Perito. Do you have a waiting list, Doctor ?

Dr. DuPoNT. We don't have a waiting list right now. We have in
the past, and we are moving in the direction of having a waiting list
again. We found that a waiting list discourages many people from
coming into the program. Only about 30 percent of the people who
sign up on a waiting list actually show up, at least in our experience.

Whenever procedures are set up as hurdles for people to get over
before treatment, act to discourage the use of the treatment, and ac-
cordingly limits the kind of people who will go over these hurdles
to get in. It is a grave step to take to build up barriers of any kind to
get into narcotics treatment.

Narcotics treatment of a continuing nature, regardless of whether
it is methadone or abstinence, is efficacious in reducing not onlv heroin
use but arrest rates. The critical question that needs to be addressed is
the issue of retention in program. Some programs exaggerate their
fiarures by counting patients who come into the program but who. for
all practical purposes, dropped out and have no continuing relation-
ship. Those patients that do have a continuing relationship and are
participating actively, whether methadone or not, do quite well. I
don't think one needs to feel he has to use methadone.

On the other hand, our experience is that for most criminal heroin
addicts the treatment of their choice and the one that seems to make
the most sense from their point of view does involve methadone. I
think heroin addicts need to have choices for themselves about what
kinds of treatment they are going to get. Our program at NT A offers
considerable choice.

Mr. Perito. Is it fair to say that your programs jjoals are similar to
the goals articulated by Dr. Gearing for the New York urograms?

Dr. DuPoNT. Absolutely. Manv of the best features of our program
have been taken from New York, including our basic goals.

Mr. Perito. Directing your attention now back to my first question,
you have compiled some recent statistics pursuant to the committee's
request.

Dr. DtjPont. Riffht. Last May 1^ we drew a sample. NTA then had
1,060 patients in treatment. We did a random sample of 450 of those
patients. Six months later, 56 percent of them were retained in the
program.

At 11 months, the figure retained had fallen to 40 percent. So that
40 percent of the people in the program last May 15 were still in the
program at the end of last week.

Now, the retention rate in the program is highly related to the use
of methadone. I don't have the followup data to 11 months on the
basis of treatment modality, but at 6 months the results were quite
striking. We found that patients who were on 60 milligrams or more
of methadone had an 86-percent retention rate at 6 months. Of the
patients who elected abstinence, only 15 percent remained in the pro-
gram for 6 months.

There is a very high dropout rate associated with abstinence pro-

145

grams, at least in our experience. Those who did stay in the abstinence
program did well. That needs to be emphasized.

Now, about the arrest rate : Of the 450 in the program on May 15,
1970, 22.5 percent were arrested in the course of the following 11
months.

Of the 186 who stayed in the program the entire 11 months, or until
arrested, a total of 25, or 13 percent were arrested.

Of the 264 who dropped out of the program, 75, or 28 percent were
arrested.

Now, further to clarify this and to attempt to get at some of the
harder data on this, Ave found that not all of the 450 people in the study
had identifiable records of detention in District of Columbia jail.
That is, we couldn't identify District of Columbia Department of
Corrections numbers on all the patients.

Mr. Perito. You had access to the criminal reference reports and
rap sheets, I assume ?

Dr. DuPoxT. We had access to the rap sheets in the Department of
Corrections so that if a person is detained in a correctional institution
we have that information.

However, if he is arrested and released before going on to incarcer-
ation we do not have the data. This has happened in minor offenses,
such as traffic cases and first offenses, but it is not common with addicts.
However, when it happens, we don't have the information.

There is a law in the District of Columbia that prohibits the police
department from releasing information to non-law-enforcement agen-
cies on arrests. We are looking into this and are seeing if we can't get
that information. It won't change any of the results, because we use
the same criteria to apply to those who are in the program and those
who drop out, and also to comparison groups.

So although the total number would change, the relative percentages
would stay the same, at least that is our assumption.

But we asked this question another way : Of those people who have
identifiable rap sheets, how many were arrested over 11 months.

We found that 19 percent of those who had identifiable rap sheets
and who stayed in the program were arrested, whereas, 99 percent of
the 145 who dropped out and w^ho had rap sheets were arrested. The
relative relationships were the same ; that is, the people who dropped
out of the ])rogram had an arrest rate over the period of 11 months
of about 214 times the arrest rate of those who stayed in the program.

Another way to look at this data is to ask, for example, about the
arrest rate for a comparison group or similar group. The most simi-
lar group we have found was the Department of Corrections narcotics-
involved releases prior to the existence of the Narcotics Treatment
Administration, and of that group 36 percent were arrested in 6
months.

We don't have the figure for 11 months, but it would be over 50
percent.

Thus for those who stay in the program there is a considerable
reduction in the arrest rate and methadone treatment is associated
with higher retention rates.

On the other hand, I am not here to say that a simple matter of
giving a person methadone is a panacea. It is not a magic method,
as some have thought, to absolutely eliminate criminal activity. But

146

there are dramatic reductions in arrest. There are some other studies
of a more impressionistic nature and certainly those of us who have
clinical experience could corroborate this, that show that heroin ad-
dicts who are in the treatment programs do in a dramatic way reduce
their heroin use and that much of their criminal behavior was driven
by their need to get heroin.

On the other hand, let's be clear that we are talking about a very
disadvantaged segment of the population, by and large, a group for
which there are often few employment opportunities, a group with
very inadequate education and a group which has developed rather
considerable skills in hustling and illegal activities.

It is therefore, hardly surprising to find that this simple matter of
putting a person in a treatment program does not in itself eliminate
criminal activity, although it clearly reduces it.

Mr. Perito. I asked Dr. Gearing about her knowledge of efficacy
studies of drug-free programs, the value of detached analytical studies,
and similar questions about the crime reduction. Do you know of any
such studies in the drug-free programs across the Nation so that this
committee can compare those results with the results of methadone
and related drug programs?

Dr. DuPoNT. I think drug-free programs have tended to get in-
volved unnecessarily in rhetoric and politics.

They tend to get more involved in this and have a hard time deal-
ing with failures. So they are quite resistant in general to doing the
kind of studies that Dr. Gearing has done and the kind of study that
T reported here which, after all, reports something less than complete
success.

Abstinence programs have a hard time dealing with their very high
dropout rates.

I don't know of any published evidence of the efficacy of any drug-
free programs that is comparable in any way with the kind of data
that Dr. Gearing has presented.

On the other hand, it is my impression from visiting drug-free
programs that they have considerable merit. The problem is that they
are not acceptable to many heroin addicts. And many people who do
start there, do drop out. So I think that any city which is thinking
about programing for heroin addiction treatment, needs to include
abstinence or drug-free programs, but it needs some perspective in
terms of their efficaciousness and their acceptability to the heroin
addicts.

I guess I could have answered that question by simply saying "No."

Mr. Perito. Doctor, at the present time, what is vour appropriation?

Dr. DuPoNT. The current appropriation for the Narcotics Treat-
ment Administration is $2.2 million with an additional $2.9 million
available to us through Federal grants.

Mr. Perito. In addition to NTA's treatment programs, are you pres-
ently carrying on any independent research in the opiate area ?

Dr. DuPoNT. Well, our research is primarily related to two ques-
tions, really :

One is trying to do some monitoring of the epidemic of addiction in
the District of Columbia, and the other is evaluating the performance
of our programs. We don't do any basic research into chemical alter-
natives to methadone, for example, or many other kinds of research.

147

Mr. Perito. Doctor, under the IND concept, as I understand it,
your program is not specifically designated as a methadone mainte-
nance program ^

Dr. DuPoNT. Well, the IND procedure does not specify what main-
tenance is, and this has been a very serious handicap in the District
of Columbia in terms of trying to come to grips with the private phy-
sicians and others who are using methadone in ways that many of us
feel are not responsible. There are regulations associated with the
Food and Drug Administration that deal with methadone mainte-
nance, but since they don't define "maintenance," it is quite possible
for people to talk about long-term or even endless detoxification pro-
grams.

They talk about 20-year detoxification programs. In other words,
there is no point at which detoxification becomes a maintenance. It
is a matter of anyone's semantics.

NTA does have an application with the Food and Drug Adminis-
tration and we have the distinction of being one of the few programs
to be audited by the Bureau of Narcotics and Dangerous Drugs. Five
agents went over our procedures about 2 weeks ago, and this was
very helpful.

But in general the Food and Drug Administration and the Bureau
of Narcotics and Dangerous Drugs make no attempt in assessing com-
pliance, either with their regulations or IND protocol that was filed
with them.

Mr. Perito. Doctor, we have heard testimony from several wit-
nesses that it was their considered judgment that a private physician
could not properly dispense methadone within an ordinary office be-
cause such physician is not able to offer the proper and necessary an-
cillary and supportive services. Do you maintain a similar opinion?

Dr. DuPoNT. Well, I asrain find myself really following in the
footsteps, to some extent, of the work that has been done in New York
City and what Dr. Gearing said today.

lit is obvious in dealing with a widespread epidemic that has clear
medical dimensions and where medical skills are valuable, that it
doesn't make sense to entirely write off the private health care sector
and trv to create an entirelv Government-run clinic system to deal
with all the problems of all the people who are currently heroin
addicts.

So I think the challensre is to find ways to make use of the private
sector in a constructive way.

I think probably a good way to start is to have private phvsicians
associate themselves with ongoing structured programs and then to
pick up stabilized to successfully adjusted maintenance patients to
follow privately.

Therefore, after a person has been in a methadone program and
demonstrated his stabilitv for 6 months or a vear, then he would be
transferred to a private physician who would handle no more than
10 or 20 heroin addict patients as part of his regular practice.

In this way we get away from part of the financial gain of private
phvsicians merelv selling prescriptions.

We don't build Government clinics to treat all diabetics. Most dia-
betics get private care. Stabilized heroin addicts can also move to the
private sector.

148

Health insurance coverage for methadone maintenance is important
once the person is stabilized. The private doctor then has the option,
if that person breaks down, of returnino; him to the public clinic from
which he came for more extensive work.

The private physician doesn't have the capability of control of
methadone that is needed in the induction phases of methadone treat-
ment. This involves more than just ancillary services. Private doctors
have made their greatest errors by p:iving unstabilized patients 1 or 2
weeks' supply of methadone right at the beginnino; so that a patient
takes out a bottle or prescription of methadone which he takes in an
unsupervised way.

I think the dangers to the public from such practices are very great
and ought to be avoided.

Mr. Pertto. Chairman Peoper mentioned tlie situation relating to
recent deaths. Do you anticipate, with tlie expansion of methadone
programs, that death is a natural incident, that there will be three or
four deaths as a result of the inevitable distribution process of your
program, either because of misuse or wrongful distribution or a situa-
tion where a nontolerant person accidentally ingests methadone in-
tended for an NT A addift ?

Dr. DuPoNT. "Well, I think that there will be deaths, and there have
been.

On the other hand, I would certainly not take a fatalistic view that
these are unpreventable and we just pass them off and go to the next
patient.

I think we need to take these methadone-related deaths very seri-
ously and to do everything in our power to try to reduce the likelihood
of that kind of event occurring. For this reason NTA issues take-home
methadone in locked boxes and child-proof bottles. We have rather
elaborate forms that the patient signs.

On the other hand, I think it is a very serious public relations prob-
lem. All of the methadone deaths that are occurring are being charged
either explicitly or implicitly to the NTA programs, and this is far
from being true.

In the last 9 months in the District we have been able to uncover
23 deaths that involved methadone, either alone or with other drugs.

In only five of those deaths was there any relationship to the NTA
program. Thus, 18 of them had nothing to do with the program.

But there were five deaths related to NTA and we do everything
we can to prevent the likelihood of that occurring again. But in a
situation where only about 20 percent of the deaths are associated with
the NTA program, we suffer the criticism for all.

Chairman Pepper. Dr. DuPont, we have had a quorum call on the
floor of the House. If you will please suspend and await our return,
we will go over and answer the quorum and be right back.

We will take a temporary recess until we can get back, to answer
the call on the floor.

(A brief recess was taken.)

Chairman Pepper. The commitee will resume session, please.

Dr. DuPont is on the stand.

Mr. Perito was inquiring of Dr. DuPont.

Mr. Perito. Dr. DuPont, have had occasion to administer cycla-
zocine or naloxone to any of the addicts in your program ?

149

Dr. DuPoNT. No ; we haven't. The only drug we have used is metha-
done.

Mr. Perito. You are probably aware of certain testimony that has
been given previously to congressional committees by Dr. Yolles who
has stated that cyclazocine and naloxone and antagonistic drugs are
one of the most promising areas of narcotic research. Do you have an
opinion, based on your experience, with antagonistic drugs?

Dr. DuPoNT. I think you are going to hear from Dr. Jaffe, who
is one of the foremost experts on the subject.

As a clinician and an administrator, there are problems with the
antagonistic drugs. Put simply, they are not acceptable to patients.
Nowhere in the country, to my knowledge, has there been any large
scale use of these drugs. The real issue — at least one of the initial prob-
lems— is that the heroin addicts don't find the antagonists helpful to
them. Most patients don't, although there are a few who do.

The other problem is that the antagonists are presented to the pub-
lic as if they were somehow more benign than methadone, for example,
or were somehow to be treated more casually.

I think this is a mistake, and I think that the antagonists that we
know of so far are like methadone in that they are only useful so long
as they are taken regularly and remain in the body ; that is, they don't
immunize the person against anything, patients have to go right on
taking cyclazocine or naloxone and we know far less about the long-
term effects of these drugs than we know about methadone.

Mr. Petiro. Two final questions, Dr. DuPont.

When you testified before our committee in October 1970 you stated
that to the best of your knowledge the addict population in AVashing-
ton was 10,400. Subsequently you reevaluated your estimate and you
have stated, to the best of my knowledge, that the addict population
is, in fact, 18,000. Would that be your estimate today, 18,000 ?

Dr. DuPoNT. Well, our current best estimate is 16,800. 1 am not pre-
pared to change that estimate yet, although it may be that the addict
population is not growing any more, as it was in previous years. We
don't have good enough measures, really, of changes in the addict
population.

But the death rate has not been going up in the District over the
course of the last 9 months. If anything, it has fallen slightly during
this period of time.

So I use 16,800 as a ballpark estimate. The only fact that is really
relevant is that there are still very many untreated heroin addicts in
the Washington community who are suitable for and interested in
treatment.

We had occasion 5 weeks ago to open up a new clinic. It was the
first new clinic NTA had opened in many months. This clinic was
swamped with patients, going from zero to 200 patients in the course
of 6 weeks.

Even though we are providing treatment for 3,000 patients we can
recruit 200 new addicts by opening a clinic for just 6 weeks. This is a
very startling demonstration that when clinics are opened they attract
patients. I think the only relevant fact is that there are thousands of
untreated heroin addicts in the District of Columbia today.

Mr. Perito. How many addicts are presently being treated in the
District either under the auspices of NTA or some other program op-
erating and funded within the District?

150

Dr. DtjPont. Well, there are no other proarrams that have anything;
like comparable numbers. I would pav that usingr our definition there
are no more than 500 other heroin addicts who are beinff treated in all
the Drop-rams in the citv. inclndina: the abstinence programs.

Including the detoxification programs and the private physicians,
it mav be that there are as manv as a thousand more patients in all.
I can't imaarine the total beino- hisfher.

Chairman Pepper. Dr. DnPont, you told u« that approximatelv half
of the peonle who were in jail here in the District were found to be
heroin addicts.

Have those figures been carried forward by the police department at
the present time?

Dr. DuPoNT. Yes: we repeated this study in January 1971, and
have not finished analvzinof it. I don't have the full breakdown yet.
But it was very sicrnificant that there wasn't an obvious reduction in
the percent. The figure is still about 50 percent.

One thing: that was quite dramatic, however, was that the percent
of druff arrests had increased dramatically. Whereas when the initial
study was done in August 1969, 10 percent of the total of all people
coming into the jail were on druq- charges. By January 1971, the
figure had risen to 22 percent of all jail intake.

This reflected the fact that far more purely drug charges were being
made by the police.

Chairman Pepper. Has there been any studv made of heroin addic-
tion among people arrested for burglary, offenses against property,
and muggings on the streets?

Dr. DuPoNT. Yes. We found that the addicts were slightly less
likely to commit crimes aarainst people than the nonaddicts coming
into the jail, but that the differences were not statistically significant.

For instance, more than half of the criminal homicides were com-
mitted by addicts.

Chairman Pepper. More than half of the homicides were committed
by heroin addicts?

Dr. DuPoNT. Right. So anybody who is reassured by thinking that
heroin-addiction-related crime is confined to shoplifting, prostitution,
and drug sales is sadly mistaken.

Chairman Pepper. I am glad to get that clarified. I thought it was
generallv assumed that heroin addicts were not very dangerous. They
were satisfied, had a sensation of feeling good, but you said half of
the criminal homicides are committed by addicts ?

Dr. DuPoNT. That is right. But this must be put in perspective.

Most serious crimes, the FBI index crimes, are property crimes. The
last time I looked at the list, 86 percent of all the serious crimes in
America were so-called nonperson or property crimes. So that addicts
are like other criminals, other criminal behavior of other people in
that the primary crimes addicts commit are property crimes.

On the other hand, if you turn the question around and you ask of
the person crimes, of the robberies, of the muggings, of the homicides,
itself, what percentage of those crimes are committed by addicts sup-
porting their habits, the answer is about one-half. This is a very
serious and very important finding.

Chairman Pepper. Half of the crimes against property and against
person ?

151

Dr. DuPoNT. It is about equal. In other words, addicts commit
about one-half of the person crimes and about one-half of the property
crimes.

Chairman Pepper. So that the heroin addiction, then, has a very
direct relationship to crime ?

Dr. DuPoNT. Absolutely, including crimes against people.

Now, again this is not a drug effect. The heroin addict who is high
is not a person inclined to commit crimes because the drug tranquilizes
the person. But he commits crimes to secure money to buy heroin, and
this need leads to desperation on the part of many addicts and they
act in ways that are extremely dangerous to themselves and others.

Chairman Pepper. Well, now, you gave us evidence, as I recall, last
year, when you appeared before our committee, that in your opinion
the average addict in the street, in the District of Columbia stole — or
had to get illegal possession by offenses against the person or other-
Avise — about $50,000 worth of property a year in order to sustain his
heroin addiction. Is that still your general opinion ?

Dr. DuPoNT. Yes. That kind of evidence comes from asking addicts
about the size of their habits and then making some assumptions
about the ways they get their money. For example, if a person says he
needs $40 a day to buy his heroin, you would figure, if he is involved in
stealing property, that he has to steal it at some discount so the total
value of the property stolen is some figure in excess of the $40.

On the other hand, there have been some studies, since I testified
before you last, that would suggest that the total amount of property
crimes in the District of Columbia, at least as reported and estimated,
is not large enough to support that assumption. So that this technique
may overstate the actual criminal activity related to heroin addiction.

On the other hand, we don't really know how much unreported
crime there is. We are also in a swampy area when we estimate how
many addicts there are. The only thing we need to know however is
that there is a tremendous amount of criminal activity associated with
drug addicts. In the District of Columbia alone, $200 million a year
is probably a low estimate.

Chairman Pepper. What do you estimate to be the average cost of
heroin addiction a day ?

Dr. DuPoNT. Well, $40 is the figure found.

Chairman Pepper. In other words, he has to get enough property
in one way or another to net $40 a day ?

Dr. DuPoxT. $40 a day. But the addict will put into his arm as
much as he can get. The limit is not the physiology having to do with
the drug, but his ability to get the money. Some days he is not as able
as others so his habit fluctuates.

Chairman Pepper. Mr. Blommer.

Mr. Blommer. Thank you, Mr. Chairman.

Doctor, we are going to have Mr. Horan, the commonwealth attor-
ney from Fairfax County, testify here tomorrow, and he believes there
is a methadone epidemic.

Dr. DuPoNT. I believe there is a serious problem with methadone
in illegal channels in this city.

Mr. Blommer. Do you accept methadone addicts in your program ?

Dr. DuPoNT. You mean people who come to us and say they have a
methadone habit from somewhere else and say they want to come into
the program ; sure.

152

Mr. Blommer. You would agree there is a black market in meth-
adone ?
Mr. DuPoNT. Yes.

Mr. Blommer. And there will come a time — I assume you are al-
ready thinking of it — when you have hard-core methadone addicts
that may have become addicts from unscrupulous doctors, from the
black market, or whatever, but now we have hard-core methadone
addicts.

Dr. DuPoNT. Most of those people are using heroin, also. It will
depend on the availability. I don't think you are going to find people
who are shooting methadone, for example, who are not also shooting
heroin. Usually they will go back and forth, and use whatever is
more available.

Mr. Blommer. Would you believe it would be efficacious to take
those people in your program ?

Dr. DuPoNT. Yes. They are j ust like heroin addicts.
Mr. Blommer. Doctor, I know we have a disagreement on statistics
and what they mean. I do have a sheet here that I believe we got
from your office that shows in the last 6 months in 1970, 60 people
that were autopsied by the D.C. coroner had narcotics in their bodies.
As I read it, 10 of the 60 died of gunshot wounds, 13 of the dead
people had only methadone in their body, one had cocaine, and one
had Talwin. Therefore, 15 of the 50 remaining after we take away
the gunshot deaths had no heroin in their bodies. That leaves us
with 35 heroin-related deaths. Could you, using whatever analysis
or formula you want, make a judgment on how many heroin addicts
there are in the District of Columbia ^

Dr. DuPoNT. I am having a little trouble following your assump-
tions. You are making the assumption that the methadone addict is
different from the heroin addict when he is pursuing addiction on
the street. In other words, methadone will compete with heroin and
produce the same effects when injected.

Injected methadone produces a high like herom. It strikes me as
sortof a question of semantics.

You could call them opiate addicts and lump them together and
talk about the frequency. . i j i -i j

For example, if it were more available, morphnie would be the drug
of choice. Today heroin is the main drug in the black market, but
other opiates would work just fine. ,

Mr. Blommer. Doctor, what I am suggesting is that it and wtien
we clear up the heroin problem that we might then be dealing with
a methadone problem. . ,

Dr DuPoNT. I don't call that "clear." We now have an opiate
addiction problem that is very serious, and if we switch from one
drug to the other, and have all the same consequences, we have gained

''''Mr!'BL0MMER. But the point is, though, Doctor, no matter who is
giving the drugs out, there will be people who will be methadone
addicts and people who are heroin addicts.

Mv question is: Don't you feel that there is a great danger that
the people becoming metliadone addicts will then ] ust come to vou
instead of to the street pusher that they used to go to for herom?

Dr. DuPoNT. Well, come to me for what ?

Mr. Blommer. For their drugs, for their methadone.

153

Dr. DuPoNT. To do what ?

Mr. Blommee. To satisfy their craving, assuming they are metha-
done addicts, to satisfy their craving for methadone.

Dr. DuPoxT. And then stay in the program and pursue the course
we are interested in in the program. So what is the problem?

Mr. Blommer. The problem is you are aiding them in being addicts.

Dr. DuPoNT. I don't see how we are aiding them in being addicts.
They were addicts before they ever got there.

Mr. Blommer. Doctor, is all the methadone dispensed by your clinic
to the 1,700 people you are maintaining, is all that consumed in front
of you ?

Dr. DuPoNT. No; the patients who are stabilized in the program
have take-home privileges and they take the methadone out with them.

Mr. Blommer. Don't you see a problem ? Couldn't those people sell
to the black market and then take heroin, for instance ?

Dr. DuPoxT. Sure ; but I think you are looking at a little thing and
overlooking a big thing. Where do you think the methadone is coming
from that is causing Mr. Koran's and other people's problems in Fair-
fax County ? It is not coming from our program. He knows that.

He has said as much. Are you saying there should be no take-home
medication? What we need is widespread availability of good treat-
ment programs, whether they are in Virginia or the District. If you
did that you would undercut tremendously the black market in heroin.
You would undercut tremendously the death rates that we are seeing,
and there would be a tremendous social gain associated with that. The
need for good treatment is the big thing. Our take-home procedures
are the little thing. We also need to do something about the uncon-
trolled, unsupervised dispensing of methadone in the metropolitan
area. Do you agree with my statement ?

Mr. Blommer. Well, to some degree; but you seem to premise that
on the fact that the black market now comes from unscrupulous doc-
tors.

Dr. DuPoNT. And perhaps other sources that I don't know about,
but I am quite sure that it is not coming from our NTA program.

Mr. Blommer. Do you have an opinion on how easy it is to manu-
facture methadone ?

Dr. DuPoxT. I talked to Mr. Ingersoll, Director of the Bureau of
Narcotics and Dangerous Drugs, and he said as far as he knew there
was no illegal manufacture of methadone.

Mr. Blommer. My question is : Do you know how easy it is to manu-
facture it illicitly ?

Dr. DuPox'^T. I don't know how easy it is.

Mr. Blommer. Did Mr. Ingersoll tell you about the laboratory?

Mr. DuPoxT. In Tupelo, Miss. They broke that one 2 years ago.

Mr. Blommer. And that man had made 50 kilos of methadone.

Dr. DuPoxT. Yes ; maybe it will be happening again. If your argu-
ment is methadone is not a panacea and needs to be thought of as hav-
ing a serious abuse potential, I agree with you.

Mr. Blommer. My argument is you should have far stricter controls
than apparently you have.

Dr. DuPoxT. There is no evidence of our methadone being a prob-
lem in terms of control. We have questioned the police to find if they
find it in illicit channels. Our methadone is clearly labeled. The police
haven't brought even one bottle that they have found of our metha-

60-296 O— 71— pt. 1—^11

154

done. Where is the evidence ? Nobody in Fairfax County has died be-
cause of our methadone. What is the problem we are addressing?

Mr. Blommer. Mr. Horan, I think, will address himself to that
problem. I don't feel I should speak for him.

That is all the questions I have.

Chairman Pepper. Mr. Mann.

Mr. Mann. Your methadone in the program is administered in a
wav to bring about stabilization, which means they don't get high off
of it?

Dr. DuPoNT. Eight.

Mr. Mann. That w^ould make it different from the street addict of
even methadone ?

Dr. DuPoNT. Right.

Mr. Mann. You mentioned there were a wide variety of choices of
programs under yours. I don't see but two, the methadone maintenance
and abstinence programs. What else is there ?

Dr. DuPoNT. To give you an example of the diversity of the pro-
grams, we have halfway houses in which people can live in where they
can in some cases take methadone and others remain abstinent.

We have 65 beds in a hospital unit for detoxification, primarily for
young people. They have programs entirely abstinent and these are
used a good deal. We have people taking it in decreased dosages, lead-
ing to abstinence and others maintained on it.

For example, in the city we cooperate with Colonel Hassan and the
Black Man's Development Center. In the Black Man's Development
Center patients go through a different experience entirely and are
educated in citizenship training, residential treatment, and decreasing
doses of methadone. That is a very different kind of treatment experi-
ence than goes on in most of the rest of our programs.

Another program, Step-One, run by ex-offenders known as Bona-
bond. Inc., is a halfway house and outpatient clinic that uses no
methadone.

A person can move freely between any of these options.

Another program. Guide, D.C., uses psychologists and social work-
ers, in family and individual therapy of patients, and for those who
find that useful, they can go to the program.

So there is quite a variety of treatment programs, perhaps not com-
plete, but quite a variety.

Mr. Mann. Getting back to the chairman's reaction to your state-
ment of crimes of personal violence. I was interested in your state-
ment that these crimes of personal violence were not motivated by the
drug effect, but were still motivated by the acquisition of property,
of funds to sustain their habits.

Dr. DuPont. Right.

Mr. Mann. Have you made any effort to distinguish those property-
related crimes, even though they result in personal violence, from
crimes of passion resulting in personal violence ?

If you were to take homicides and divide them in half you would
find that half passion and half property ?

Dr. DuPoNT. Right. I haven't looked at that, but that is a good
question. I will look into that and maybe I can supply something for
the record on those crimes committed in our previous study.

Mr. Mann. Very good.

Thank you, Mr. Chairman.

(The information referred to above follows:)

155

100 addicts

125 nonaddicts

Offense with which charged

Profit Passion

Profit

Passion

Larceny

Robbery

Burglary

11 ...
15 ....

8 ...

3 ...

1 ...

Stolen property

Housebreaking

Offense/family

Assault

5 ....
3 ....

Homocide

Assault/deadly wea pon

A rmed robbery

2 ...

1 ....

3 ...

2 ....

Bank robbery

Forgery

Fraud

Manslaughter

Private orooertv

Total

Total (percent)

8
8

46
37

20
16

Note.— Table Is a result of study conducted by the Narcotics Treatment Administration at D.C. Jail between Aug. 11 and
Sept. 29, 1969, on an accidental sampling of 225 Inmates.

Chairman Pepper. Mr. Wiggins.

Mr. Wiggins. Dr. DuPont, I am still a little bit confused on the
effect of methadone on the human body. When it is taken by a patient
in your program, what effect does it have on that patient ?

Dr. DuPoNT. Well, the regular effect is that the person comes into
the program and he has an opiate habit which is in almost all cases,
at least as far as I have ever seen any data, a heroin habit.

When he comes he wants some help with that, and he will take an
initial dose of methadone of around 30 to 50 milligrams. Now, when
he takes that he has a suppression of the withdrawal of symptoms
that he usually experiences and he feels relatively normal.

Now, the patient has choices at that point, and he can either go on
decreasing doses leading to abstinence, taking anywhere from a few
days to a few months ; or he can choose a maintenance schedule in which
his dose goes up to about 100 milligrams and he stabilizes at that point
until he feels it makes sense to try detoxification and comes down
again.

Depending on the amount of the drug, and if there is a little bit
more given than is needed just to suppress withdrawal symptoms, the
person might feel a little drowsy, a little euphoria.

He would also, in many cases, experience constipation. Some people
will also experience excessive sweating. Those are the primary effects.

In addition, while the person is on increasing doses or beginning
treatment, some men have a transient impotence, probably associated
with the anesthetic effect of the drug. The mechanism is not clear.

Once he is stabilized, the only effect that most patients experience
is the constipation and excessive sweating. In other words, there is
tolerance to the other effects, except suppression of the opiate drug
craving and the blocking of the euphoric effects of heroin.

Mr. Wiggins. Is there any benefit of feeling good by going out and
getting more methadone if you are on a diet of 100 milligrams ?

Dr. DuPoNT. No. Once on 100 milligrams there is no effect either
orally or injected. Now, many patients do go out and shoot methadone
or heroin to test their blockade. He will not have any euphoric or other
effect.

156

There are several reasons a person might continue occasional use of
heroin. Many persons are fearful about withdrawal symptoms and
feel they must take increasing doses to prevent withdrawal symptoms,
even though they can't feel the drug effects. But they feel very anxious.
We had one patient who, when a private doctor recently stopped his
practice of giving methadone, said, "Oh, I didn't want to tell you this,
but I was getting a second dose of methadone by going to a private
doctor." Since there is no central registry now we didn't know that.
He was taking two doses of methadone each day. "V^Tiat he was doing,
as far as we can understand, was treating his anxiety about not getting
enough.

The treatment was to counsel the patient, to help him see that he
was getting enough methadone, and he stopped taking two doses.

Mr. Wiggins. Dr. DuPont, we are running out of time, and I would
like to get into the record the technique you employed to prevent peo-
ple from abusing your program by obtaining methadone from a sec-
ond source, and the way that you insure that those who take it home
do not misuse it. Would you describe your security procedure?

Dr. DuPoNT. The NTA patient takes his methadone on the premises
for the first 3 months of the program, and then he gets take-home
privileges of gradually increasing duration until the minimum fre-
quency allowed, which is two clinic visits per week. The patient must
be on the program at least 6 months to a year for that to happen.

The patient's urine is tested twice weekly. Urine tests identify all
hard drug use, but, of course, we can't separate a second dose metha-
done. But we know that a person is not going to more than one of our
centers, because all patients come in and have their pictures taken and
get an I.D. card. It is, however, possible to take methadone from an-
other source, either inside the city or out, which is a serious problem.

Mr. WiGGixs. What w^ould be an in-city source ?

Dr. DuPoNT. A private physician. A person could also go to Colo-
nel Hassan's program and register for that program and receive meth-
adone and not be in our central register.

Mr. Steiger. Is he still conducting his program ?

Dr. DuPoxT. Yes ; and only those patients for whom we pay him in
our central registry.

Mr. WiGGixs. What is the solution to that problem ?

Dr. DuPoxT. The solution is a regional registry for everybody who
gets methadone. Everybody who takes a dose of methadone anywhere
in this area ought to be required to be in a central register.

Mr. WiGGGixs. How central ? IMultistate ?

Dr. DuPoxT. We should ultimately involve Baltimore as well as
the suburban counties in Maryland and Virginia.

Mr. Steiger. I wonder if we could have the witness, if he could re-
main? I hate to impose on him, but I think all of us would like to ex-
plore this.

Chairman Pepper. Doctor, could you wait a few minutes more?

Dr. DuPoxT. Sure.

Chairman Pepper. Doctor, let me make this announcement before
we recess. We will come back.

Dr. Jaffe is here, another distinguished witness, and he has kindly
consented to stay over until tomorrow morning. Without objection on

157

the part of the committee, when we do recess today we will recess un-
til 9 :45 tomorrow morning.

AVe will take a temporary recess so we can go over and vote again,
Doctoi'. We are sorry to put you to so much trouble today.

(A brief recess Avas taken.)

Chairman Pepper. The committee will come to order, please.

Dr. DuPont, I understand you have some problems with time to-
day, also.

Dr. DuPoNT. Yes ; I do.

Chairman Pepper. We will try to expedite our examination of you.

Mr. Steiger.

Mr. Stei«er. Thank you, Mr. Chairman.

Doctor, I wanted to get into one thing about half opened up by
your testimony and others, that physicians are a source of the illegal
methadone. I notice that in almost all the drug hearings we have had,
and the committee has held before, even in other areas, there is a great
reluctance to admit the complacency of the medical profession. I say
"complacent" advisedly. I don't mean there is any kind of conspiracy
by the medical profession itself, as a major source of opiates.

I wonder if in your experience, Xo. 1, if you agree that it could
be a problem not only in methadone, but in the dispensing of other
opiates, and if the equation that the reason for many of the people
involved in your program and the New York City program are the
underprivileged as an economic matter that the privileged are able
to buy through pseudolegitimate source the wherewithal to feed their
habits : is this a valid position ?

Dr. DtPoxT. There are so-called medical addicts or people who
have become addicted through medical treatment. This does not neces-
sarily involve any dereliction on the part of the physician, although
oftentimes there is less vigilance than probably was appropriate.

On the other hand, I don't think it Avould be fair to say that opiate
addiction is uniformly distributed throughout the population by so-
cial class and that the lower classes don't have the wherewithal to get
it and the upper classes do. Opiate addiction is concentrated in the
loAver social classes, even adding in people going to private physicians.

On the other hand, those who do go to private physicians are ob-
viously from the upper classes. One thing we have noticed in the Dis-
trict is that whereas about 8 peicent of the overdose deaths in the city
are white, only about 4 percent of our patients are white, which means
that there is an underrepresentation of whites in our patient group.
I am sure that this is accounted for by more white addicts going to
private physicians.

Mr. Steiger. That is a very interesting statistic and I can draw a
lot of conclusions from it, which I don't want to do superficially, but
I am glad to have these statistics.

Now, we have had some specific instances in the Phoenix, Ariz., area
in which physicians were actually dispensing narcotics in a manner
that could hardly be determined medically responsible. I don't think
it serves any purpose to identify it as a racket, but just as irrespon-
sibility.

My question is : In your experience, how widespread — I will phrase
it a different way.

158

It would seem to me a very busy physician who finds it reasonably
profitable and could justify perhaps in his own mind the regular pre-
scription of opiate prescription for persons who didn't require much
attention, and to which he was going to get paid for each prescription.

Dr. DuPoNT. In advance.

Mr. Steiger. In advance. Is that the way it works ?

We have now taken public official notice of the private physician in
regard to dispensing of methadone, and your recommendation there
is that he not be permitted to do this without other qualification,
which I think is very valid, but really we are still skirting the prob-
lem.

Dr. DuPoNT. It is still going on. ,

Mr. Steiger. Well, Ko. 1, of course, there is no way to control it, we
understand that. We all know we are talking theory here. Short of
having the AMA speak to its own, what do you recommend ?

Dr. DuPoNT. Well, the AMA has spoken to its own. They had a
release about a month ago in which they strongly discouraged private
doctors.

I think it is going to take something more than this. I am not an
attorney, but what I understand is that once a drug, any drug, is avail-
able in the pharmacy, any pharmacy, that any doctor can prescribe
it for anything he wants to. There are certain recommendations that
are made by the medical profession and by the Food and Drug Ad-
ministration, but these do not have the force of law and the doctor can
pretty much do what he wants.

Methadone is an established drug available in every pharmacy. I
wonder if it wouldn't require some sort of legislative action to make
methadone an exception and to bring it under control.

You might pursue this with subsequent witnesses who can speak
more authoritatively, because I think it is a very serious problem when
Federal agencies and other groups pretend to have the power to curb
certain kinds of behavior that are considered to be undesirable but
really don't have that power. The question is whether thev do have
the power; if they do have the power, then why has nothing been
done?

I think many people are misled and believe that power exists when
it doesn't.

Mr. Steiger. Good.

Thank you. Doctor, I have no further questions.

Chairman Pepper. Is that all ?

Mr. Steiger. Yes.

Chairman Peppek. Mr. Kangel, have you inquired of Dr. DuPont?

Mr. Rangel. Doctor, in your medical experience, have you ever
found a national health problem such as drug addiction being treated
as you are treating it with — and multimethods of service and com-
munity controls? Is this a usual way to treat a problem of such
enormity ?

Dr. DuPont. I don't think there is anything usual about heroin
addiction. I don't know what the analogy would be. I think it is very
exceptional.

Mr. Rangel. This is a very exceptional method of treatment of any
problem, any medical problem of this sort, isn't it ?

Dr. DuPoxT. I think so. I am not sure where I am being led to, but
I will say, "Yes," and put an asterisk after it.

159

Mr. Rangel. Well, I wasn't goin^ to lead you any further, but I
wonder if we were talking about a different economic class of people,
whether or not those in the medical profession would be more prone
to have this type of community control over dispensation of drugs.

Dr. DuPoxT. That is a good point. If it were a different social class
I don't think the problem would have gone on in Harlem as long as it
did without any treatment at all. It wasn't until the majority of the
country, the more affluent part of the country, in any event, became
very frightened about crime rates in their cities, and until they got
concerned about their own junior and senior high school children using
drugs that we got a national commitment.

But it is coming and I think it is to everybody's benefit.

Mr. Rangel. This national commitment, as far as I can see in the
area of rehabilitation, it has settled down to the question of expand-
ing methadone treatment ; has it not ?

Dr. DuPoxT. No ; I don't think that is true.

Mr. Raxgel. How much time does your institution spend on devel-
oping scientific methods of curing this, other than methadone ?

Dr. DuPoxT. Well, about 25 percent of our patients are not on
methadone, for example.

Mr. Raxgel. But are you looking for other scientific cures ?

Dr. DuPoxT. No; we don't do any basic research. That would be
more properly done elsewhere. We are a city treatment agency.

Mr. Raxgel. But you have no national institution that you can go to
in order to increase your ability to deal with the drug addiction prob-
lem ; do you ?

Dr. DuPoxT. Well, the National Institute of Mental Health is prob-
ably one of the logical sources for this kind of activity. In fairness to
them, some activity is going on there, but very little.

Mr. Raxgel. Have they been of any assistance to you to reach a
program Avhere you could professionally feel that you are doing the
best you can with what is available ? Have they assisted you in devel-
oping your program ?

Dr. DuPoxT. Yes; they have given us $800,000 a year for one major
component of our program.

Mr. Raxgel. I am not making myself clear. I am not talking about
the money. I am talking about you, as a doctor, with your background.

Dr. DuPoxT. I see.

Mr. Raxgel. Have you got a national institution that can give you
scientific data as a result of their research that you can depend on so
that perhaps you could expand and develop other methods of treating
drug addicts, other than methods of Colonel Hassan ?

Dr. DuPoxT. No.

Mr. Raxgel. So that as far as you are concerned, all you have is what
New York City has done as a basis of where you are going ?

Dr. DuPoxT. Well, I think Chicago and Dr. Jaffe added something
very important to the New York experience, and that was the concept
of a multimodality program. So I think there are other additions, and
I think all over the country there are a lot of very resourceful and
energetic people who are involved from a variety of sources.

For instance, in Stanford University, Professor Goldstein, who is a
pharmacologist, made a very important contribution, for example, with
a urine testing technique which promises a lot of advantages over what

160

we had before. I don't think it is quite fair to say there is no where
to turn.

Mr. Kangel. I am talking about on a national level.

Dr. DuPoNT. I think the national agencies have provided very little,
approaching nothing.

Mr. Kangel. You said earlier that there was no difference between
a heroin addict and a methadone addict, and I agree with what you
and I have seen in central Harlem.

On the other hand, other people have testified there is no difference
between a methadone addict and a diabetic. I see a large medical
credibility gap between those two statements.

Dr. DuPoNT. Well, I think Mr. Blommer and I were talking about
the "addict" as different from the "dependent." Dr. Gearing made
this distinctioii. We are going to have to make a distinction between
the person who is taking methadone and is dependent upon it as part
of a structural program and the so-called addict. Both are technically
addicted, although the behavior one observes is quite different.

Mr. Kangel. Let me just use your terminology. Is there any dif-
ference between a person dependent on heroin and a person dependent
on methadone ?

Dr. DuPoNT. Yes; I think there is a dramatic difference. It is as-
sociated with the drug and also with where it comes from.

Mr. Kangel. Didn't you say earlier there was no difference between
a heroin addict and a methadone addict ?

Dr. DuPoNT. When it is out on the street and people are shooting
it and are pursuing an addict life style, there is no difference.

Mr. Kangel. To put it another way, if we were to dispense heroin
or have a heroin maintenance program, then would there be any dif-
ference, taking out the life style of the street and heroin maintenance
program and your methadone maintenance program?

Dr. DuPoNT. Yes ; there would be. I think there are pharmacological
advantages to methadone, which is very important. One is that metha-
done needs to be taken once a day instead of three or four times a day
as with heroin. That is a very important distinction.

Another difference is that methadone can be taken orally rather than
injected. Many of the problems associated with heroin addiction have
to do with its being injected.

Perhaps even more important, methadone allows the person to be
stabilized at a dose and he doesn't continue to crave for increasing
amounts.

The fact is that most people "maintained" on heroin — for exam-
ple, in the British clinics — are dropouts from society. This is not the
typical experience with the methadone-dependent patient in a pro-
gram. He is a person who is able to call on his own inner strength and
pursue a life course that makes sense, including productive prosocial
work.

I think the personal experience of seeing the persons in a methadone
program is dramatic.

I was with the Department of Corrections a little oyer 2 years ago
and had no interest in or special knowledge about this field. I went
through a very personally moving experience when I first visited a
methadone program and talked to the patients. This experience meant
more to me than all of Dr. Gearing's charts. But I was impressed by

161

the sincerity of many of these people as they described the difference
of their lives and their families after methadone treatment. You talk,
for example, to the wives of men who are in the program, and they
are appreciative of the changes that have come about in their
husbands.

Mr. Eangel. You can't attribute all of this to methadone.

Dr. DuPoNT. No, I don't. I think a lot of it has to do with the pro-
gram, but I think the programs could not function without methadone.
If you put a head-to-head kind of test with just the ancillary services
in one and the other you had the ancillary services plus methadone,
you would get 10 percent effect in the one with ancillary services and
90 percent in the other.

I don't think you should underestimate the effect of methadone in
dealing with chronic heroin addiction.

Mr. Rangel. But you don't know if you were able to give all of
these services to youngsters not addicted to anything whether or not
you would still feel great that you were helping youngsters ?

Dr. DuPoNT. I think youngsters need all of the services, regard-
less of whether they are taking heroin, especially employment oppor-
tunities. There are great segments of our society who don't have
enough opportunities now, whether they are on a program or not.

That is another thing that happens to you when you work with these
people, vou learn that.

Mr. Rangel. Would you consider your patients normal? Some-
one said earlier, a witness testified that they believed that the metha-
done patient would always be dependent on drugs. Now, you have
different programs, but you do have one that does not try to diminish
the amount of methadone, and is it fair to say that the person included
in this program will always be dependent on methadone ?

Dr. DuPoNT. No ; it isn't fair to say that, because some will try at
later points to come off and some of those people will make it.

Mr. Rangel. During this period of time, how do you as a doctor
distinguish between them and so-called normal people who are

Dr. DuPoNT. You can't tell any difference. The only way is the
urine test.

Mr. Rangel. But how do they function ?

Dr. DuPoNT. Methadone maintained patients function perfectly
normally. To add to this a little bit, I have never seen this in writing
and I hope it is not denied, but it is, I understand, the case that the
District of Columbia Motor Vehicles Bureau has been very interested
in how our methadone people have been faring in terms of accidents.
Although they have a list of quite a number of our patients asking
for permits about whom we have written saying they are rehabilitated.
So far, these patients haven't had the first accident. The Motor Ve-
hicles Bureau said facetiously, that methadone maintenance may not
only reduce crhne but also reduce auto accidents.

But I think the point is very important. These people do perform
normally.

The same thing goes on with employers. As Dr. Gearing said, em-
ployers are quite skeptical about methadone. Many have learned from
experience that methadone maintenance patients make good employees.

But again I want to emphasize what I think you are saying, which
is that there are vast unmet needs in the community which spawn

162

heroin addiction and support all kinds of destructive behavior. Meth-
adone does nothing about those problems.

Mr. Rangel. Thank you.

Chairman Pepper. Mr. Keating.

Mr. Keating. Doctor, did I understand you earlier to indicate that
there were 26 deaths attributed to the methadone, or did I hear you
incorrectly ?

Dr. DuPoNT. Twenty-three that involved methadone. Not all you
could say could be attributed to methadone, because many of them
also had heroin as well. There were a total of 14 of the 23 that did not
involve heroin also.

Mr. Keating. Breaking that down, did you indicate that five were
associated in some way or another with your group ?

Dr. DuPoNT. Five out of the 23 and three out of the 14.

Mr. Keating. How were you able to determine if these were asso-
ciated with a drug dispensed by your organization ?

Dr. DuPont. Well, two of them were patients who were in our pro-
gram 2 days, one of whom took heroin and alcohol along with the
methadone and died of a multiple overdose.

The second was a young woman who was in the second day of the
program and felt sick in the evening after taking her dose at 8 o'clock.
She went to bed, vomited in her sleep, inhaled the vomit into her
lungs, and died. Those were the only two patients to die of overdoses.

A third death was a person who was put into a cab and who was
about to die of an overdose. The cab raced to the hospital but the
driver noticed that the person who put him in the cab threw some-
thing into the street that was not identifiable. The policeman was told
about this. When he came back and looked in the street he found a
bottle with an NTA label. But we count that as a death that may have
had something to do with our methadone. Two other cases occurred
when people not in the treatment program were given bottles of NTA
methadone and died of overdoses. Both included heroin as well as
methadone ; that is, they participated in an addict drug-taking experi-
ence which involved methadone.

That is the total : Five.

Mr. Keating. Have you had any deaths that were attributed to
people who took the methadone from the clinic to take at home or as
a result of that procedure ? You know, you have some people that only
come in twice a week.

Dr. DuPoNT. No patient who has been on the program longer than
2 days has died from an overdose of anything.

Mr. Keating. I think that helps clear up a number of questions I
had. How do you ascertain the previous experience of the patient in
terms of heroin or methadone or some other drug?

Dr. DuPoNT. We ask them and record the information about when
they say they first begun to use each of the numerous illegal drugs,
including methadone and heroin.

We also take a urine test at the beginning of the treatment. It re-
mains possible for a person who is not an opiate addict to get into our
program and to continue to participate in the program without ever
having been an opiate addict.

For example, if a person would drink a bottle of tonic water, such
as gin and tonic, it would produce quinine in the urine, which is a com-

163

mon finding with people iisino; heroin. We would tabulate that as
heroin "positive." But such an impostor would have to drink the meth-
adone on the NTA premises for 3 consecutive months and give us a
urine sample twice a week. We haven't had any investigators or re-
porters that pursue that course. Whether there are people, children or
otherwise, who have gone through this process and are not bona fide
addicts in the first place, we don't know.

Mr. Keating. How do you know what level to start them ?

Dr. DuPoNT. On the basis of what they tell us. A person who is
young would get a smaller dose and a person without a lot of track
marks would get a smaller dose, and an older person with a lot of track
marks would get a larger dose. In all cases, the dose is from 20 to 50
milligrams to start.

Mr. Keating. Do you have any information of somebody coming in
and getting started in your program ? I think this question was asked
earlier. Is that a constant concern of yours ?

Dr. DuPoNT. I am concerned about it from a theoretical point of
view. I don't have any evidence of that happening. My impression is
it is unlikely because the methadone treatment in my experience is not
a positive one in terms of pleasure. It is certainly disruptive to a per-
son's life to come in every day for 3 months and fill out all the forms,
get an I.D. card, and to give us urine specimens twice a week. This
would deter, I think, a casual fake from coming in.

On the other hand, I am concerned about it and if there was some
evidence to the contrary I would like to know about it. We are really
quite concerned. There isn't any obvious way to find that out, though.

Mr. Keating. You indicated a patient needs a choice of modality.
How many different choices do you provide?

Dr. DuPoNT. There are 15 centers in the city right now, not that
everybody can choose each one of them. For example, some of them are
restricted to geographic areas. So if a patient doesn't live in that geo-
graphic area he can't go there. But every person can choose at least
detoxification on methadone with dex^reasing dosages, or methadone
maintenance, unless he is under 18 years of age or reports a history of
addiction less than 1 year, in which case he cannot choose methadone
maintenance. Each patient can choose an abstinence program and come
in and give a urine sample and participate in counseling programs.

Mr. Keating. Do you check any police records as part of your
procedure, before you put them on your program?

Dr. DuPoNT. No. This is certainly a good thought. We are now con-
sidering trying to identify arrest records earlier, and if we can't, to
make extra efforts to make sure we have the correct identification.

Our initial attempts to make positive identification were not as
strict as they are now. Our current procedure is to find a driver's
license or something else to confirm identification.

In other words, we just don't take the person's word for his name,
the way we did earlier in the program. Everybody who now has his
identification renewed is expected to go through' this same process
of proving who he is.

Mr. Keating. Is there any procedure during the course of your
treatment that would lead to a counseling that would try to persuade
the person to abstain ?

Is there any effort in this direction ?

164

Dr. DuPoNT. I am reluctant to get involved in encouraging that
unless there is some reason to believe it is likely to succeed. It is very
hurtful to people to talk them off methadone when they really need to
be on it. We have had some very bad experiences with people who
have discontinued methadone under some overt or covert staff pres-
sures and then who go back to heroin and leave the program.

Mr. Steiger. Excuse me.

Mr. Keating. Yes.

Mr. Steiger. A person who is addicted or dependent on methadone
in the oral form, and he abstains, are his withdrawal symptoms phys-
ically as stringent as the heroin addict ?

Dr. DtrPoNT. They tend to be, dose-for-dose, less intense and of
longer duration, but, of course, the dose-for-dose qualification is im-
portant because the street heroin addict is likely to have a smaller
total dose. The peo]:)le who are on methadone maintenance have very
painful withdrawal symptoms if they stop abruptly. If they detoxify
over weeks or months the common experience is easy until the patient
is down to about 20 or 30 milligrams a day, at which time he will start
developing hunger for the drug again and he may start shooting heroin
again.

When he takes his last dose of methadone, if he doesn't go back to
heroin, he will have insomnia, aching of his joints and muscles, which
will last for several days to several weeks.

Chairman Pepper. Mr. Brasco ?

Mr. Brasco. Thank you.

There are several observations that have been made, Doctor, and it
is sort of puzzling me. I share the concern of my colleagues about the
problem of methadone traffic in the street. It would appear to me that
if there is no euphoria attached to drinking meliadone, then there
would be no need or no reason for an addict to be taking it in the street,
unless

Dr. DuPoxT. He shoots it, they inject it.

Mr. Brasco. All right. Now, the next thing is if he does that and
based on my own experience in the area, having practiced criminal law
for some 10 years, addicts are not stupid when it comes to their own
needs.

Are the problems that you talk about concerning greater withdrawal
effects in usmg methadone, and obviously if they are obtaining it
illicitly they are paying for it anyway. Wliat would be the advantage
of using methadone when an addict can get heroin in the streets easily.

Dr. DuPoNT. Well, if the methadone is cheaper he would take the
methadone, and I think with the widespread availability of methadone
on the street it is cheaper, dose for dose.

Mr. Brasco. So what you are basically saying is that the people that
are trafficking in the street are using it to shoot it up because of the
availability and the fact that it is cheaper ?

Dr. DuPoxT. Oh, yes.

Mr. Brasco. One other thing.

I agree with my colleague, Mr. Rangel, that the support programs
surrounding the methadone program that Dr. Gearing talked about, if
they were given to underprivileged people without the problem of
addiction they would be very effective in doing a job to lessen crime
rates in deprived areas. But in your program I am wondering whether

165

or not there is great resistance in the job opportunity areas, based on
two reasons :

One, the fact that the individual is an addict in your program ; and
two, this question of the previous record of an individual, which seems
to me probably to be the most destructive force that we have in our
area of rehabilitation. I am wondering if we were able to devise some
kind of system where we could do away with a criminal record follow-
ing you around for the rest of your life, whether or not that would be
helpful in terms of the effectiveness of your program, at least the
followup portion, the job aspects?

Dr. DuPoNT. Well, it might be. It certainly wouldn't hurt. But I
think you have to keep in mind that the average educational level of
the patients in our program is 10th grade. That is, half the people have
dropped out by the time the 10th grade has come around. So we have
some serious handicaps here of an educational nature that are not
going to be dealt with simply by eliminating the arrest record.

I think in some respects I would like to put in a qualification on the
ancillary services and dealing with the patients' problems. I don't
know where the evidence is about job training, for example, or psycho-
logical counseling in terms of reducing unemployment, or many other
things.

I think that the whole manpower question really needs a very hard
look at what is going: on. I am taking the position that it is not just
training that is needed, but opportunities for work. You can have a
lot of training go on and put an awful lot of money into training pro-
grams that don't really go anywhere.

Mr. Brasco. Let nie just rephrase the last question another way:

Getting away from the program that you are talking about and in
the area that you are expert in, do you think that cari-ying a prior
record around for the rest of your life serves any purpose other than
to deprive people of job opportunities ?

Dr. DuPoNT. I think it does deprive people of job opportunities,
but, perhaps, not as many as you may be thinking. It is possible in many
circumstances to establish an identity as a rehabilitated former offender
that is quite positive and constructive.

I don't think it is necessarily a bar forever. There is some evidence
of social change about this. Businesses, I think, now are more con-
cerned about social responsibilities in terms of reducing criminal be-
havior by providing job opportunities, more so than they were 5 years
ago.

Mr. Brasco. Thank you.

Chairman Pepper. Dr. DuPont, I just want to ask you one question :

You estimated there were 16,800 addicts of heroin in the District of
Columbia. You testified you had 3,160 in your treatment program and
most of the rest of them are not being treated.

Now, how much money would it take, according to your best esti-
mate, to provide the best known treatment to all the addicts of the
District of Columbia?

Dr. DuPoNT. Mr. Chairman, our best estimates are that it costs
about $2,000 a patient-year to provide comprehensive multimodality
treatment.

That amount of money in no way meets all the needs of these people,
including health and training, et cetera. But it meets many of them.

166

Using this figure as rule of thumb, it would take about $34 million
to treat 16,800 heroin addicts.

Chairman Pepper. You are now getting a total of about $5,100,000
for the program from the District and Federal Governments ?

Dr. Du Pont. Yes sir.

Chairman Pepper. Well, thank you very much. Doctor. We appreci-
ate your coming.

I am sorry to have kept you so long.

We want publicly to thank Dr. Jaffe again for his willingness to
stay over and let us hear him tomorrow morning.

We will recess until 9 :45 tomorrow morning, in room 2253, and we
win be back in this room at 10 o'clock Thursday.

Without objection, the insertions will be included in the record.

Mr. Perito. For the record, Mr. Chairman, exhibit No. 11(a) is en-
titled "Profile of the Heroin Addiction Epidemic."

Exhibit No. 11(b) is dated January 12, 1971, and entitled "Summary
of 6 Months Follow Up Study."

Exhibit No. 11(c) is in the handwriting of Dr. DuPont and is en-
titled'JDr DuPont's Numbers."

Exhibit No. 11(d) is dated January 1971 and entitled "Administra-
tive Order."

Exhibit No. 11(e) is entitled "A Study of Narcotics Addicted Of-
fenders at the D. C. Jail."

(The exhibits referred to above follow :)

[Exhibit No. 11(a)]

Profile of a Heroin Addiction Epidemic

(By Robert L. DuPont, M.D., D'rector, Narcotics Treatment Administration,

Washington, D.C.)

Abstract

Washington, D.C, is experiencing an alarming epidemic of heroin addiction.
According to current estimates there are now about 17,000 heroin addicts in the
city.

Two-thirds of the addicts are under 26 years of age, 91 percent are black, 74
percent are male, and 52 percent began heroin use within the last 4 years. In one
large part of the central city it is estimated that 20 percent of the boys agei 15
to 19 and 38 percent of the young men 20 to 24 are heroin addicts.

A major treatment program has been implemented in Washington which is now
treating 3,000 heroin addicts of whom about 75 percent receive methadone.

An initial performance study found that 55 percent of all patients remained in
the program after 6 months and that 86 percent of those on methadone main-
tenance were retained in the program during the 6-month study. Among the
patients treated, heroin use decreased, arrest rates fell, and employment rates
rose.

Introduction

Washington, D.C, Is engulfed by an alarming epidemic of heroin addiction.
Increasingly sophisticated research information accumulated over the course of
the last year demonstrates this without a doubt. It is now estimated that there
are 16,800 heroin addicts in the city, or 2.2 percent of the total population of
756,510. The social and personal losses are tremendous. The related crime rate is
appalling.

But the figures do not stop with the tragic consequences of heroin addiction in
the Nation's Capital. Limited data available from metropolitan areas around the
country suggests that these cities are also experiencing the epidemic.

Upon recognizing that heroin addiction was such a disastrous problem in
Washington, D.C, the largest and fastest growing municipal treatment program

167

in the Nation, the Narcotics Treatment Administration, was begun in February
1970. Nevertheless, it is obvious that even this effort is grossly inadequate for
the needs of the Washington community.

What is known of the epidemic in Washington? How many heroin addicts
are there? Where do heroin addicts live in the city? What are the basic char-
acteristics of the addict population? When did the epidemic begin? Is it getting
worse? What is the relationship between the distribution of addiction in the city
and other social factors including crime and poverty? How much does the
epidemic cost the community ? What can be done about it?

This paper attempts to answer these vital questions and should be useful to
the Washington, D.C., community and to other cities and States which know far
less about their problems with heroin addiction.

How many heroin addicts are there?

In the summer of 1969 the only basis for estimating the Washington addict
population was the Bureau of Narcotics and Dangerous Drugs (Justice Depart-
ment) 1968 list of 1,162 addicts in Washington. However, in August 1969 a study
at the District of Columbia jail showed that 45 percent of all new admissions
were heroin addicts. Only 27 percent of the men identified as addicts by inter-
view and urine testing were previously known to the BNDD (1).

On the basis of this new information, the estimate of the total number of
addicts was raised to 3.7 times 1,162 or 4,300 addicts. Next, in cooperation with
the District of Columbia coroner, an analysis was made of the total number of
known opioid overdose deaths in Washington. An opioid overdose death is a sud-
den death, without other cause, of an individual whose urine or other tissues
contain an opioid drug such as heroin, morphine, or methadone (3). In 1967 the
number was 21. Using the Baden formula (2) that one of every 200 heroin addicts
dies of an overdose reaction each year, the total number of District of Columbia
heroin addicts appeared to be 4,200 for 1969. However, there were 13 overdose
deaths in the first 3 months of 1970. This was equivalent to 52 per year and indi-
cated a total addict population of 10,400 using the Baden formula. During the
first 6 months of 1970 a total of 21 people died of overdoses. Thus, in the first 6
months of 1970, the same number died of overdose reactions as died in all of 1969.

In July 1970, again in cooperation with the District of Columbia coroner, a
new more systematic procedure was developed. Complete narcotics drug screens
(using gas liquid chromatography) were performed on all autopsied deaths of
individuals between the ages of 10 and 40 as well as individuals younger or
older who showed evidence of drug use. During the next 6 months, 42 people were
identified as dying of opioid overdose reactions. The annual rate was 84. The
estimate of total heroin addicts was accordingly raised to 16,800.

During the calendar year 1968 a total of 875 narcotic addict information forms
were received by the Biostatistics Division of the District of Columbia Health
Services Administration. In 1969 one of these individuals died of an opioid over-
dose. During 1970 three died of opioid overdose reactions. Thus the rate of death
was one per 438 man-years. This data was not used to compute a '^Washington
formula" because the numbers are small, but it suggests that the multiplier used
by Baden in New York may be low for Washington. If this is true, then the cur-
rent estimate of 16,800 heroin addicts in Washington may also be low.

It should be noted that the increase in the rate of overdose deaths in the last
2 years did not reflect only increased heroin use. In part, the increase was due to
greater awareness of the problem of overdose deaths and to improved and more
frequently used laboratory procedures. For example, during the 18 months prior
to July 1970 drug screens were performed on only 6.3 percent of all autopsied
deaths. During the last 6 months of 1970, the period of the systematic study,
narcotic drug screens were performed on 51 percent of all autopsied deaths. ( See
table 1. )

There was no evidence of increasing death rates over the 6 months of the study.
Twenty-three people died from July through September, and 19 died from October
through December 1970. Thus, although the time span was short, and the numbers
were small, the Washington heroin addiction epidemic may have stabilized during
the last 6 months of 1970. Data collection is continuing and in the next year more
definitive conclusions should be possible.

By January 1971, a private drug treatment program located in the District of
Columbia, the Blackman's Development Center (BDC) which made small doses
of methadone available to addicts as part of a voluntary outpatient withdrawal
program, had registered over 20,000 "drug dependents" — almost all heroin addicts.
Some BDC clients lived in the Washington suburbs, which have almost no treat-

168

ment facilities for heroin addicts. However, it seems unlikely that the suburbs
contributed more than 10 to 20 percent of BDC registrants. Thus, even when the
BDC registration list is discounted for suburban residents, nonheroin users and
multiple registrations for the same person, the 20,000 figure suggests that there
are many more thousands of addicts in Washington than the 1968 list of the
Bureau of Narcotics and Dangerous Drugs indicated.

There are other figures which indicate that the addiction problem is greater
than had previously been estimated. The Washington, D.C., Metropolitan Police
Department reported 4,730 narcotics arrests during 1970. Ninety percent of these
arrests related to heroin use or sale. The numbers of narcotic arrests for each
year from 1967 through 1969 were 818, 1,077 and 1,716 respectively. Thus, there
was a 462 percent increase in narcotics arrests from 1967 to 1970. Undoubtedly,
part of this increase reflects improved and increased police activity. However, it
also reflects the spreading epidemic of heroin addiction.

Evidence for increasing the estimate of the total number of heroin addicts in
Washington comes from several relatively independent sources. These include
the rate of commitment of narcotics offenders to the jail, the rate of opioid over-
dose deaths, and the rate of narcotics arrests. More direct evidence comes from
the universal experience of Washington heroin addiction treatment programs
which report large numbers of registrants.

No one piece of evidence is conclusive. However, taken together, the data form
a pattern which clearly indicates that the number of heroin addicts in Washing-
ton is far higher than earlier estimates. Tlie evidence also suggests that there
has been a major increase in the prevalence of heroin addiction in the last several
years.

What are the characteristics of the addict population?

In February 1970, Washington began a large multimodality treatment program,
the Narcotics Treatment Administration. By January 14, 1971, there were 2,793
heroin addicts in treatment in the NTA programs.

Study of the 77 onioid overdose deaths in 1969 and 1970 revealed demographic
characteristics of the group on the four basic variables of age, sex, race, and
place of residence in the city. This population was then compared to the NTA
patient population using these same four variables. The results are shown in
figures 1 and 2.

There was a close correspondence betAveen these two populations. This sup-
ported the assumption that NTA was reaching typical addicts and, unlike vir-
tually all other drug programs in the country, the treatment population was
generally representative of the total Washington addict population.

Some of the basic characteristics of this population are shown in table 2.

When did the epidemic of heroin addiction tegin?

Assuming that the NTA patient population is representative of the total Dis-
trict of Columbia addict population, it is possible to determine when the heroin
addiction began for Washington addicts. (See fig. 3.)

Fifty^two percent of the Washington addicts began heroin use after 1965 and
65 percent began after 1963. This data indicates that the epidemic began between
1964 and 1966 and became increasingly widespread at least through 1968.

The individual who has become addicted only recently is often less motivated
to seek treatment for his addiction since he is still enjoying the "high" of the
drug and has experienced relatively little of the pain and danger of addiction.
Thus, most treatment programs have an overrepresentation of older, more chronic
addicts. This reluctance of the newer user to seek help probably explains the
sharp drop in the number of addict patients who began use during 1969 and
1970. However, it seems certain that the rise in addiction between 1964 and 1968
reflects a serious epidemic of heroin addiction in Washington. This is corro-
borated by a recent study of the rate of commitment of known addicts to the
District of Columbia jail between 1958 and 1968 which shows a sharp increase
occurred in 1967 (4). (See fig. 4.) This increase also corresponds to a sharp rise
in reported serious crimes in Washington in 1966. ( See fig. 5. )

A recent St. Louis study (5) suggests that the list of the Bureau of Narcotics
and Dangerous Drugs of known heroin addicts, which is derived primarily from
police data, generally offers a good estimate of. total number of addicts in a
community when the total is stable. The data may not be reliable, however, in
a community which is experiencing a sudden epidemic of heroin addiction. The
District of Columbia jail study showed that there is a substantial time lag be-
tween beginning addiction and coming to the jail. For example, the average

169

period of addiction prior to the current incarceration was 7 years (1). Ttiere-
fore, the discrepancy between the St. Louis data and the District of Columbia
data may reflect the acute epidemic in Washington in recent years. This hypo-
thesis gains some support from the fact that the BNDD list for Washington rose
sharply from about 1,100 each year from 1965 through 1968 to 1,743 by December
31, 1970. The earlier BNDD figures for Washington for 1965 through 1969 were:
1,116, 1,164, 1,106, 1,162, and 1,636.

Where do heroin addicts live in the city?

Based on the opioid overdose deaths and NTA patients, and assuming that
there are a total of 16,800 heroin addicts in the city, it is possible to describe a
geographic profile of addiction in the city.

( See table 3 and fig. 6. )

The rates of heroin addiction range from less than 0.1 percent for the rela-
tively affluent northwest section of the city west of Rock Creek Park, to the rate
of 4 percent in the model cities area, area 6. These rates of addiction closely
parallel reported crime rates and other indicators of poverty and social
disorganization.

(See table 4.)

Using this same data it is possible to estimate the number of addicts per
thousand people in various sex and age groups in the Washington, D.C.,
population.

From statistics based on opioid deaths, several conclusions can be drawn.
Addiction is concentrated almost exclusively between the ages of 15 and 45.
Sixty^five percent of the addicts are under 26 and 31 percent are younger than
21 years of age. For the age range 15 through 19, the citywide rate for boys is
10.7 percent and for girls 2.2 percent. The next older age bracket, 20 through 24,
has rates of 19.8 percent and 3.2 percent respectively for boys and girls. From
25 through 29, the rates are 6.2 and 5.0.

( See fig. 7 and table 5. )

Relating this data to the geographic distribution data and using the distribu-
tion of NTA patients indicates that in service area 6 (the model cities area) 20
percent of the boys between the ages of 15 and 19, and an astonishing 38 percent
of the young men between the ages of 20 and 24 are heroin addicts. The District
of Columbia model cities area begins six blocks north of the White House, and
extends east above Massachusetts Avenue to four blocks north of the U-S.
Capitol.

How much does the heroin addiction epidemic cost the community?

The most certain and tragic cost of heroin addition in 1970 was the 63 people
who died of opioid overdoses. In addition, almost all heroin addicts commit
crimes to support their expensive habits. Based on an estimate of 15,0(X) heroin
addicts, and assuming an average habit of $40 per day, a recent study estimated
that the annual value of proijerty and services transferred because of addiction
through robbery, theft, prostitution, drug sales, et cetera, was $328,100,000 (6).
One of the common ways to support a habit is to sell heroin. This spreads the
epidemic. The indirect costs of heroin addiction to the community from urban
disorganization and fear of crime are equally staggering.

What can be done about the epidemic?

Heroin addiction is a treatable disease for most addicts. There is excellent
evidence that methadone maintenance is safe and effective (7). Therapeutic com-
munities (such as Synanon, Day top, and Phoenix House) and community self-
help organizations (such as Blackman's Development Center in Washington)
offer promise of success with many addicts.

A recent study of the narcotics treatment administration program perform-
ance with 475 randomly selected patients for the 6-month period from May 15
through November 15, 1970, showed that 55 percent of all patients in the program
on May 15 were still in the program 6 months later. The retention rate for high
dose methadone maintenance was 86 percent after 6 months. Arrest rates were
down and employment was up for the patient population. Only 7 percent of the
patient population was still regularly using illegal drugs and 55 percent showed
no evidence of illegal drug use during the sixth month of treatment (S).

Seventy -six percent of NTA patients were voluntary, self -referred walk-ins
to one of the 10 NTA centers located throughout the city. Twenty-four percent
were referred by agencies of the criminal justice system, such as probation and

60-296 O— 71— pt. 1 12

170

parole departments. None were civilly committed. About 100 lived in three NTA
halfway houses. Seventy were residents almost always for less than 3 weeks, on
two NTA detoxification wards at District of Columbia General Hospital. The
remainder, about 2,600, were outpatients. Fifty-four percent were receiving
methadone maintenance, 26 percent were in abstinence programs, and 20 percent
were receiving decreasing doses of methadone leading to abstinence.

The unprecedented, sharp dip in the rate of serious crimes in Washington
during 1970 (see fig. 5) was widely attributed to increased police presence and
particularly to the effectiveness of the NTA treatment programs (9) .

How much do treatment progrwms cost?

An economic study of drug addiction demonstrates that if NTA can suc-
cessfully treat only 40 percent of 1,000 patients (a low estimate on the basis of
performance studies) the cost of treatment for 1 year will be $1,400,000. The
benefits in terms of reduced criminal activity will be $5,750,770. This shows a
benefit-cost ratio of 4.1 to 1 (6).

On January 14, 1971, when NTA had 2,793 patients, the total cost »f the pro-
gram was less than $4 million a year.

References

(1) Kozel, N., Brown, B., DuPont, R. : "Narcotics and crime: a study of narcotics

involvement in an offender population." Narcotics Treatment Administra-
tion, 1971.

(2) Glendinning, S. : "District of Columbia coroner's office study." Narcotics

Treatment Administration, 1970.

(3) Johnston, E. H., Goldbaum, R., Welton, R. L. : "Investigation of sudden

deaths in addicts." Medical Annals of the District of Columbia, 38: 375-
380, 1969.

(4) Adams, S., Meadows, D. F., Reynolds, C. W. : "Narcotic-involved inmates in

the Department of Corrections." District of Columbia Department of Cor-
rections Research Report No. 12, 1969.

(5) Robins, L. N., Murphy, G. E. : "Drug use in a normal population of young

Negro men." Am. J. Publ. Hlth., 57 : 1580-1596, 1967.

(6) Holahan, J. : "The economics of drug addiction and control in Washington,

D.C. : a model for estimation and costs and benefits of rehabilitation."
Special Report by the Office of Planning and Research of the District of
Columbia Department of Corrections, 1970.

(7) Gearing, F. R. : "Successes and failures in methadone maintenance treatment

of heroin addition in New York City." Presented at the Third National
Conference on Methadone Treatment, Nov. 14, 1970.

(8) Brown, B. S., DuPont, R. L. : "6-month followup of heroin addicts in a large

multimodality treatment program." Narcotics Treatment Administration,
1971.

(9) DuPont, R. L. : "Urban crime and the rapid development of a large heroin

addition treatment program." Presented at the Third National Conference
on Methadone Treatment, Nov. 16, 1970, accepted for publication in J. Am.
Med. Assoc, 1971.

Table 1. — The number of opioid overdose deaths each month from, July through

December 1970

July 9

August 5

September 9

October 8

November 7

December 4

Total 42

Average per month 7

171

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/,•

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Caucasian NeQro

IL'%

AH%

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/ -

Female tAo-lc

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ili%

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1 1

3 V

SBHUiCk pif^ea OF REbiPkNCE

172

Table 2. — Selected characteristics of the NT A patient population (N=2T59)

Percent

Reporting regular heroin use prior to treatment 99

Average number of arrests reported prior to treatment 4. 7

Average number of convictions reported prior to treatment 1. 7

First drug used :

Heroin 9

Marihuana 49

Heroin and marihuana in same year 7

Other 35

Average age at first heroin use 19

"Voluntary admissions 76

Referred from agencies of the criminal justice system 24

Civilly committed 0

Reporting prior treatment for heroin addiction 41

Martial status :

Single 58

Married 23

Separated 13

Divorced 4

Widowed or deserted 2

Last year of school completed, average 10. 4

Receiving welfare at start of treatment 7

173

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174

TABLE 3.— HEROIN ADDICTION RATES BY SERVICE AREA

Heroin overdos

e deaths

from April through

NTA clients (random

Estimated

Number

November,

1970

sample

of 500)

total
number

of addicts
per 1,000

Number

Percent

Number

Percent

of addicts 1

population 2

6.5

6.6

1,109

13.3

3.4

571

10.9

13.0
19.6

55
62

11.0
12.4

1,848
2,083

19.9

18.0

8.7

14.2

2,385

27.7

28.3

121

24.2

4,066

40.2

21.7

121

24.2

4,066

30.8

0.4

0.8

2.2

3.6

605

14.6

Service area

Total

100

500

100

16,800

21.2

1 Based on 16,800 estimate of total number of addicts distributed according to percent of NTA patients or service area.

2 Based on 16,800 estimate of total heroin addicts and distributed according to percent of NTA patients by service area.

Note.— Service area population used were 1967 estimates.

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Number "BcoKs-d

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TABLE 5.— CITYWIDE HEROIN ADDICTION RATES BY AGE-SEX GROUPINGS i

(In percent]

Males

Females

Total

15tol9 12.9 2.0 7.1

20to24.... 18.9 3.0 10.5

25to29 _ 6.3 4.7 5.5

30to34 5.4 3.4 4.4

35to39 4.3 .9 2.5

40to44 2.5 .7 1.5

45 to 49

50 to 54 _.. .7 .4

' Based on 1968 population statistics, age-sex distributions of 91 overdose deaths (August 1968 through November 1970),
and total estimated addict population of 16,800.

177

Number In
Thousands

38
36
34
32

30
28
26
24
22
20
18
16
14
12
10

FIGURE FIVE

CRIME INDEX OFFENSES
1959 THRU 1970

SIX MOKTH TOTALS

■

'■ \ \ ' • 1

—

-—

CRIME INDEX OFFENSES
Murder
Rape
Robbery
Agg. Assault
Burglary

Larceny (over $50)
Auto Theft

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, '^ \

^ 1

r"^

^-f^

—

^ 1 -

' — p^

DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC JUN DEC

58 59 60 61 62 63 64 65 66 67 68 69

D. C. SERVICE AREAS

AND

ns7o

CENSUS TRACTS

PREPARED BY THE D C GOVERNMENT
AND
NATIONAL CAPITAL
PLANNING COMMISSION

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178

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[Exhibit No. 11(b)]

GOVEBNMENT OF THE DiSTBICT OF COLUMBIA, NABCOTICS TbEATMENT

Administbation, Office of the Dieectob, Washington, D.C.

Januaby 12, 1971.

SUMMAEY of 6-MONTH FOLLOWTJP STUDY

There were 1,060 heroin addict patients in treatment with the Narcotics Treat-
ment Administration on May 15, 1970. iSix hundred and twenty-five (625) of these
were randomly selected and followed for 6 months by the Research and Develop-
ment Division of the NTA.

The Youth Division of NTA differed significantly from the adult programs and
is therefore considered separately.

There were 475 patients in the adult program sample on May 15, 1970. Six
months later, on November 15, 1970, 217 (46 percent) of these people were still
active and reportable* with their original NTA program. In addition, 43 (9 per-
cent) were active and reportable in other NTA programs into which they had
transferred. Thus, a total of 55 percent of the clients reportable to NTA as of
May 15 remained reportable to NTA 6 months later (table 1). Eighty -nine (19
percent) of these 475 had been arrested for a new charge during the 6 months
followup period.

The highlights of this followup study are reported in tables 1 through 4.

It is noteworthy that there is a much higher retention-in-program rate in high
dose methadone treatment than in other treatment classifications (table 1).

The high dose methadone group not only achieves this high retention rate (86
percent) , but also has the lowest arrest rate (12 percent) (table 2) .

The arrest data was also examined comparing the arrest rate of individuals in
the NTA programs with the arrest rate of those who left the program. The former

♦A patient Is "reportable" If he has been seen at least four times In the 14 consecutive
calendar days preceding the weekly NTA census.

179

had an arrest rate of 2.8 percent per patient-month of treatment while the latter
(the dropouts) had an arrest rate of 5.7 percent per month after leaving the
program.

Table 3 reports arrest rates after 6 months in the community for heroin addicts
released from the Department of Corrections before the start of NTA in 1970.
This table is included for comparison purposes.

Tables 4 and 5 contain data on employment rates and dirty urine rates. Both
are encouraging but suggest the need for increased counseling and job placement.

The 150 patients in the youth program fared less well (see client's functioning
in the Youth Division programs — ^May 15, 1970 — Nov. 15, 1970). Only 1 percent
of these youths received methadone maintenance treatment while an additional
10 percent received either methadone detoxification or emergency short-term
methadone treatment (methadone hold). Thus 89 percent of the sample never
received methadone. Forty-two percent of the youth clients were arrested during
the course of the 6-month followup. Sixty of the 150 youths remained in the pro-
gram after 6 months (40 percent retention rate) but only 18 of these were still
giving regular urine samples (12 percent of 150).

The results of the Youth Division program were generally similar to the
results of the abstinence programs for adults. The results of the abstinence pro-
grams are not as encouraging as the results from high dose methadone mainte-
nance treatment. However, it must be emphasized that while there were many
failures in the abstinence programs there were at least a few apparent suc-
cesses— for example while 42 percent of the youths were arrested during the 6
months followup, 58 percent were not arrested.

This summary relates to NTA's performance with patients who were in the
program from May 15 through November 15, 1970. 'Since May 15, there have been
some improvements in our programs and a great enlargement. On January 8, 1971,
NTA had 2,670 reportable patients. Of this total 1,402 receiving methadone main-
tenance treatment, 526 were on methadone detoxification, and 35 were on emer-
gency doses of methadone (methadone hold). Thus 1,963 (74 percent) were
receiving methadone and 707 (26 percent) were abstinent.

180

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183

[Exhibit No. 11(c)]
Dr. DuPont's Numbers

Of 1,060 patients in NTA on May 15, 1970, 450 were randomly selected for
foUowup.

Of these 450, 56 percent remained in the program for 6 months, and 40 per-
cent remained for 11 months.

Of those on methadone maintenance, 86 percent remained 6 months as com-
pared to 15 percent who received no methadone (or were abstinent).

After 11 months, 22 percent of the 450 were rearrested. Of the people who re-
mained in the program, 13 percent were rearrested. Of those who dropped out,
28 percent were rearrested in 11 months.

In the last 8 months, 23 people have died of overdoses with methadone. Only
five of these got their methadone from NTA.

[Exhibit No. 11(d)]
Administration Order

1. purpose

The purpose of this administration order is to provide medical and program
guidelines for methadone treatment in Narcotics Treatment Administration pro-
grams and cooperating programs.

2. DEFINITIONS

New admissions are persons who have no previous record in Information
Central.

Readmissions have l)een previously known by NTA central information but
their cases have been deactivated.

Reportable patients are defined as patients who have been seen at least four
times in the preceeding 14 consecutive calendar days.

Reportable patients will be considered to be in one of the following four
categories :

1. Abstinence

2. Methadone maintenance

3. Methadone detoxification.

4. Methadone hold.

Nonreportahle patients are seen at least once in the preceding 28 days but do
not qualify as reportable.

Transfers are any patients known to Information Central who undergo an
approved change in treatment centers.

Inactive patients are defined as those who have no face-to-face contact during
the preceding 28 days.

Abstinence is defined as any continuing treatment contact with the Narcotics
Treatment Administration program or cooperating program in which the indi-
vidual patient does not receive methadone.

Methadone maintenance is a treatment classification to be used for all pa-
tients who receive regular doses of methadone when the dose of methadone is
not consistently reduced. That is, any patient who receives a regular dose of
methadone at the same dose level or increasing dose level is to be considered
a methadone maintenance patient.* All patients in the methadone maintenance
category should be urged to stay on methadone maintenance until their life
situations have been stabilized for a period of 6 months to 1 year or longer. Any
patient who comes off methadone maintenance should be strongly urged to stay
in the treatment program while he is being detoxified and after he is abstinent
for a period of not less than 2 months. During this time, urine testing and coun-
seling should continue while the patient is considered an "abstinence patient."
If there are signs of renewed drug hunger and the patient feels he cannot con-
trol this urge, or if there are signs of renewed drug use, the patient should be

* The only exceptions to this definition are the special youth detoxification schedules
which have a period of Increasing doses, a plateau, and a programed detoxification within
6 months of the first dose.

184

encouraged to return to methadone maintenance treatment for another pro-
longed period of time. Experience has shown that patients who stop meihadone
mamteuance have a high relapse rate, especially it ihey have been on the metha-
done maintenance program less than a year. Therefore, every effort shuula be
made on the part of program staff to retain patients in continuing treatment for
a period of weeks or months after the patient begins a detoxification program.
Patients in methadone maintenance should be treated with regular doses of
methadone between SO and 120 milligrams a day. Dose levels less than SO mini-
grams are discouraged because of the likelihood of continued drug abuse. Doses
above 120 milligrams are to be discouraged because it is unlikely that they will
produce additional benefits to the patient. Under no circumstances are patients
to be given more than 150 milligrams of methadone a day.

Methadone detoxification should in no circumstances be prolonged for more
than 3 months. A patient on detoxification should not receive more than 50 milli-
grams a day unless he is being detoxified from methadone maintenance. The
physician in charge of the patient's treatment should establish a schedule for
gradually decreasing doses with abstinence to be achieved between 2 weeks and
3 months after the start of methadone detoxification. Urine results must be
monitored carefully in this group because of a strong likelihood that they will
experience renewed drug hunger and return to illegal drug use, particularly at
dose levels below 40 milligrams a day. Evidence of renewed illegal drug use or
drug craving beyond the individual patient's ability to control it are indications
for the patient's going on methadone maintenance. Under no circumstances
should a person be classified as methadone detoxification for more than 3 months.
Methadone hold patients are classified in this group if they are given doses of
methadone on an emergency basis prior to appropriate examination, diagnosis
and disposition. Under no circumstances should a patient be retained in the
methadone hold category for more than 2 weeks.

Authorized medical representatives. Only physicians can sign prescriptions.
Others, including nurses, medical assistants etc., may dispense methadone and
sign NTA Form 6 (attachment 5).

3. POLICY

Because people who are addicted to heroin often have many psychological and
vocational problems requiring vigorous and effective treatment, IsTA's goal for
each patient is social rehabilitation. Methadone treatment must be considered
within this context as only one part of the total treatment program.

The heroin addict patient may suffer from a number of medically treatable
illnesses and for each of these, of course, the appropriate medical treatment is
indicated. For example the heroin addict may have clinical schizophrenia with
the common symptoms of that illness. In this case, the most appropriate medical
treatment includes a phenothiazine.

Nevertheless, the only drug that has been shown to be useful in the treatment
of heroin addiction itself is methadone. Therefore, no other drug should be
prescribed for treatment of heroin addiction. For example, there is no evidence
that tranquilizers or hypnotics are useful in the treatment of heroin addiction
or heroin withdrawal. Furthermore, these drugs are specifically contraindicated
in the treatment of heroin addicts since they are likely to become drugs of
abuse in their own right. This is particularly true of the hypnotics (such as
Seconal and doriden) but it is also true of the antianxiety tranquilizers (such
as librium and meprobamate). The heroin addict has, in part, gotten himself
in serious trouble because of his tendency to medicate himself and to treat
his unpleasant feelings with a variety of drugs, especially heroin. Therefore,
the physician dealing with heroin addicts can anticipate requests from the addict
for medications of all kinds. The doctor should be armed with the knowledge
that no tranquilizer or hypnotic has been shown to be useful in the treatment
of heroin addiction. He should share this information with the patient. How-
ever, the physician should avoid routine use of either type of drug. The physician
should never prescribe these drugs for more than a few days because of the
likelihood of producing dependence on, or even addiction to, these drugs.

Meth<idone maintenance, on the other hand, has been demonstrated to be
effective in achieving specific results. The primary drug result is blocking the
"drug craving" which usually occurs at a dosage of about 40 to 50 milligrams
a day. When maintenance levels reach about 100 milligrams a day, there is
an additional important drug effect : the suppression of euphoria from intra-

185

venously administering heroin. These are the two effects that are most desirable
in the use of methadone maintenance for chronic heroin addiction. Methadone
maintenance does not produce the suppression of all anxiety, depression, or
other uncomfortable bodily feelings. Neither the addict nor the doctor should
expect these results.

Methadone in adequate doses, blocks the drug hunger for heroin and the
high of heroin. It does not alter other forms of drug abuse. Therefore, the
clinician should be watchful for signs of other drug abuse such as amphetamine,
barbiturate, and most especially alcohol abuse. Each of these conditions is serious
and requires prompt, appropriate, and vigorous treatment.

4 PR0CE3)URES

Methadone may be used in three treatment categories : methadone mainte-
nance, methadone detoxification, and methadone hold. The following are in-
dividual discussions of each :

I. Methadone Maintenance

A. Indications for methadone maintenance

The indications for methadone maintenance are :

1. The patient volunteers for methadone maintenance;

2. The patient has used heroin continuously for at least one (1) year ;

3. The patient is at least eighteen (18) years old. (Exceptions to this
ruling are discussed in section I, I. Methadone Maintenance Treatment for
Youth.)

B. Preparing the patient for methadone maintenance treatment
Methadone maintenance treatment is entirely voluntary for all patients. No

one should be forced or coerced into methadone maintenance. If the patient ex-
presses the desire to go on methadone maintenance, the implications of treat-
ment must be carefully and completely explained to him.

Prospective methadone maintenance patients should be encouraged to think
of it as, at least, a 6-month commitment to continue the treatment. For most
patients it makes sense to continue methadone maintenance for years until
their social, psychological, and biological life has been satisfactorily stabilized.
The preliminary results of our investigations into program performance indi-
cate that the premature discontinuance of methadone maintenance and dose
levels under 80 milligrams per day are often associated with the patient's re-
turn to heroin addiction and criminal behavior.

C. Consent to take methadone maintenance treatment

Before beginning methadone maintenance treatment, each patient must sign
NTA Form 19 "Informed Consent to Take Methadone Treatment" (see attach-
ment 1). If a patient is under 21, every effort should be made to get either a
parent or guardian signature on the consent form, although this may not be
possible or practical in every case. In addition, NTA Form 7 (see attachment
2) must be completed on each patient and registered with Information Central
before any medication or treatment services are provided.

D. Dose level

For all NTA treated patient's receiving methadone maintenance treatment,
the physician should attempt to give a "blocking" dose of 80 to 120 milligrams a
day. There is good reason to be'ieve that lower doses are associated with signifi-
cantly hisher failure rates and that lower doses do not produce any advantage
to the patient.

Methadone maintenance programs have been shown to be effective only when
methadone is used in a specific manner. The drug is given to the patient once
a day, and the patient's dose is modified on the basis of his response to the medi-
cation. The initial dose level should be moderate, in the range of 20 to 50
milligrams.

NTA medication schedules (see attachment 3) provide all necessary informa-
tion for raising or lowering doses, depending on the treatment indicated, by age,
size and duration of habit, et cetera. Since the duration of action of methadone is
24 to 48 hours, the drug lends itself to daily administration.

The dose level should be increased to a level of about 100 milligrams a day
in those patients who can tolerate this dose level without excessive drowsiness

60-296 0-^71— pt. 1 13

186

or other side effects. This increase should occur gradually over a 3- to 6-week
period.

Patients are not to be told their dose level since this leads to an unhealthy
'"competition" among the patients for the highest doses. Dose level is a medical
issue and it should be managed by the medical staff.

E. Side effects of methadone

Side effects of methadone include excessive sweating, constipation, edema,
drowsiness, dermatitis, and relative impotence in men. None of these symptoms
are serious, and, with the exception of excessive sweating, they usually disappear
as treatment is continued and tolerance is attained. However, some patients con-
tinue to suffer from constipation. This can be treated symptomatically with a
laxative, but even this is usually not needed once a tolerance develops.

F. Take-home medication

Methadone is to be administered to the patient daily (6 or 7 days per week
depending on the number of days the center is opened) on the premises of an
NTA facility for the first 3 months of his treatment. Once the patient's drug
use has ceased for at Idast 1 month and he has demonstrated stability in his life
patterns, he may take home his weekend medication at the discretion of the
appointed person in charge and after signing NTA Form 22 "Statement of Re-
sponsibility for Take-Home Medication" (see attachment 4).

Individual doses to take off NTA premises must be properly labeled with the
patient's name, the date the dose is to be taken, and the specific program name
and telephone number. The label must also state that the bottle contains metha-
done and that it is dangerous and may be fatal if taken by anyone other than the
patient.

Patients are to return all empty bottles before new bottles are given. If the
patient fails to return his bottle, loses or breaks it, or reverts to drug use, he will
be required to report in daily again for at least 4 weeks.

Because methadone may be fatal when taken by a nonaddicted person in doses
conventionally given to methadone maintenance patients, patients taking medi-
cation home must keep it in the locked container provided by the center. The
fact that methadone is packaged in a liquid form makes it particularly attractive
to children. The patient must be impressed with the danger involved in taking
medication home and be strongly encouraged not only to lock up his methadone,
but to place it out of children's reach.

In addition, the patient should be reminded that methadone should not be
refrigerated.

G. Urine testing

Every methadone maintenance patient must submit a monitored urine speci-
men a minimum of once a week.

These urine collections must be monitored by an NTA staff member or a staff
member of a cooperating program under the general direction of the program
chief. Unmonitored specimens are worthless for our purposes and should be
discarded.

All staff who are monitoring urine should sign the urine specimen label found
on the back of NTA form 6 (see attachment 5). These staff members should be
trained so they recognize an adequate quantity of urine. No urines should be
reported back from the laboratory as quantity not sufficient (QNS) : the staff
should discard urines of inadequate quantity.

In unusual cases, or where there is special concern about the possibility of
patients continuing to use illicit drugs, three or more samples a week may be
sent to the laboratory for analysis.

H. Suspension from methadone maintenance program

Patients failing to report for treatment for 30 consecutive days will auto-
matically be suspended from treatment. The suspended patient will have to
wait 30 days before he is eligible for treatment or the waiting list again.

If the center physician and/or the center administrator suspends a patient
before 30 consecutive days without treatment have elapsed, the physician or
administrator must complete NTA form 0 "Report of Pntirvt Chnnor of Status"
(see attachment 6) 'and send it to Information Central. Tr^ this case, the patient
will not be accepted back into treatment or placed on the waiting list for 30 days
after the suspension date.

187

I. Methadone maintenance treatment for youth

For purposes of treatment planning (as opposed to legal considerations re-
garding consent) patients are considered adults if they are 18 or over.

Individuals who are less than 18 may receive methadone on short or long
detoxification schedules (none longer than 6 months) after notifying the director
of NTA.

In the future, NTA may try an experimental maintenance program for youth
under 18 but our experience is too limited to make a final decision on that issue
at this time.

II. Outpatient Methadone Detoxification

A. Eligibility

Outpatient methadone detoxification should be attempted with the following :

1. Any patient who has a history of less than 1 year addiction to heroin ; or

2. Any patient who is under 18 years of age ; or

3. Any patient who requests this treatment.

B. Dose level

Methadone detoxification should begin by "catching" the addict's habit, usual-
ly with doses in the range of 20 to 50 milligrams per day. ( See medication sched-
ules, attachment 3.)

Initially, this may require doses more than once a day until the proper dose
level is achieved so that the patient does not experience vdthdrawal symptoms
(too little methadone) or excessive drowsiness (too much methadone). This
holding dose should then be reduced very gradually over a 2 to 12-week period.
Drug hunger should be anticipated at dosages of less than 40 milligrams per day.

C. Urine testing

Regular urine testing and monitoring should be followed as in the methadone
maintenance program. ( See section I, A for details. )

Reemergence of regular heroin use is a sign of withdrawal treatment failure.
If this occurs, the patient should be encouraged to switch to a methadone main-
tenance program (if he is eligible) at blockading doses of about 100 milligrams
per day.

D. Exceptions

If a patient fails at outpatient withdrawal even if he has used heroin for
less than 1 year or if he is less than 18 years, he may be considered for
methadone maintenance if he volunteers for this treatment. However, under
these circumstances, the director of the NTA must be notified of each such ex-
ceptional patient.

III. Physical Examinations

Every patient receiving methadone must have a physical examination per-
formed by a physician within 30 days after the first dose of methadone. Physical
exams should occur as soon as possible.

IV. Records

A. Medical records

Patients who take methadone must have physical examinations and medical
histories performed by a licensed physician or medical student working under
the supervision of a physician. The results of these examinations must be in-
cluded in the patient's clinical record and the date of physical examination must
also be noted on NTA Form 10 (see attachment 7. )

Form 10 "Record of Patient Prescription" must also be used by the physician
to record all new NTA patients' medical treatment, or major changes in treat-
ment of an existing NTA patient.

B. Accountability of methadone

Each bottle of methadone liquid (1,000 cc. ) disbursed to the centers for pa-
tient treatment will contain an envelope showing the same registered number as
that appearing on the label affixed to the bottle.

Everytime a patient has received a dose of methadone, a copy of NTA form 6,
"Record of Patient Activity," (see attachment 5) used to record the amount of
methadone disbursed, will be filed in the envelope containing the same registered

188

number as that on the bottle. When the large bottle is emptied, the envelope
containing the NTA forms 6, showing total disbursements (1,000 cc. ) will be
sealed and returned to Information Central via messenger. The forms in the
envelope will tell the pharmacist the date, the dosage level, and names of the
patients who were served out of that particular bottle. All doses of methadone
dispensed must be strictly accounted for at all times.

C Discrepancies

NTA form 14, "Director's Discrepancy Notice" (see attachment 8) will be
used to notify the physician of any discrepancies in recordkeeping or NTA pro-
cedures as noted by the computer.

The following are some items which may be noted :

1. Dosage level higher than that prescribed by the physician.

2. Irregular dosage level.

3. Consistently dirty urine.

4. No physical examinations within 30 days of initial intake.

5. Discrepancy in methadone medication disbursement.

6. Lack of proper patient evaluation.

7. Apparent lack of patient progress.

8. Exception to take-home medicine policy.

D. Confidentiality of records

The Narcotics Treatment Administration respects the basic right of patients
to have all information and treatment records maintained with strict confiden-
tiality. NTA regards this effort as vital to the establishment of an effective treat-
ment relationship with its patients.

For this reason, only Information Central is authorized to release information
on patients to vertified requestors. With the exception of criminal justice and
civil commitment patients and patient-employees, no information on any patient
will be released unless :

1. The patient has signed and Information Central has received NTA
form 28 "Patient Consent for Release of Treatment Information" (see
attachment 9) specifically authorizing the requestor access to information:

2. Information Central has received the request for information in writ-
ing ; and

3. Information Central has verified the current status of the patient vis-
a-vis the requestor.

Criminal justice system patients are those who have been formally referred
to NTA by the police, courts. Department of Corrections, or parole board as a
condition of release to the community. Requests for information on these patients
by the agency must be honored immediately by the program chief or his designee.
The request and the response should preferably be made in writing and the
current status of the patient vis-a-vis the requestor verified before the informa-
tion is released. Information should be released in the form of treatment sum-
maries whenever possible.

Civil commitment patients are those brought to an NTA facility under signed
pickup orders by the Narcotics Squad of the Metropolitan Police Department.
The results of their diagnostic evaluation and determination of their treatment
status is automatically forwarded to the referring agency — the Metropolitan
Police Department.

Patient-employees are staff members of NTA who also remain in a treatment
status with NTA. They will be required, as a condition of employment, to remain
free of illegal drugs, and must agree to release information on their urine
surveillance reports and pertinent medical summaries to their immediate super-
visors, program unit chiefs, and the coordinator of counselors. Such information
will not be shared with other staff members but can be used as a basis for
disciplinary action or suspension of employment if confrontation does not result
in termination of illegal drug use.

Minors under 21 years of age should be encouraged to authorize a parent or
guardian to receive at least a summary statement of their treatment status.

Emerfjcneirs arising when an NTA patient is confined because of arrest, ill-
nes.s, or accident will receive immediate attention. Every effort will be made to
assure the patient immediate medical assistance to maintain his medication
level for the duration of the emergency upon request from the medical authori-
ties attending the patient.

189

Attachment One

Informed Consent to Take Methadone Treatment in the Narcotics

Treatment Administration

I, , understand that methadone treatment for chronic heroin

addiction and its consequences is a new use of an established drug. I further
understand that methadone is a powerful and addictive narcotic drug and that
if I stop taking it I will experience serious withdrawal symptoms. Although
methadone treatment has been used successfully by thousands of people through-
out the country, I also understand that the long-term effect of this drug on
humans is not entirely known at this time.

I willingly give my informed consent to take methadone under the careful
supervision and control of the NTA staff or NTA cooperating agency staff. I
have tried to stop using illegal drugs and I now think that methadone is neces-
sary for me to avoid further use of illegal drugs.

I have not been forced or pressured into this dec' '■ion. I understand that I
can stop methadone treatment at my own discretion and that the staff may
terminate me at their discretion. If I do stop methadone treatment for any
reason, I understand that for my own safety I should withdraw from methadone
by using gradually reduced doses of the medication under the control of the
medical staff.

Signature and date

Printed or typed name

NTA patient number

Program name

"Witness

Signature and date
NTA FORM 19(10-70).

ATTACHMENT TWO ,

1.0. NO.

PATIEfJM!) NAM ■ " -

^OCRGE NC Y . ADDRESS iMoTJiERyRtLAIiyEO " ..

CENTER ASSIGNED

TRANSFERRED TO (Cente,^ Date)

SOCIAL SECURITY NO.

BIRTHOATE

DATE NO. ASSIGNED

PHONt NO.

WgiKING NOW?
□ YES □ N8

EXMRATION DATE

EMPLOYER'S NAf€ 4 ADDRESS (If WORKING) '

DATE PICTURE SCHEOUlfO

DATE PICTURE TAKEN

NTA FORM 7 (8.70) RECORD OF PATIEKT 1.0. NUFfiER ASSIGNED

190

Attachment Three
To all medical staff

On schedules 10, 11, and 12, the value of X (the initial dose) must be speci-
fied on the initial prescription along with which schedule is being used.

On schedule 12, it must be specified at what does the schedule stops.

Day

1 .

2 .

3 .
4

5 .

6 .

7 .

8 .

9 .
10

Detoxification schedule 1
Milligrams Day :

1 Detoxification completed.

Day

1 .

2 .

3 -

4 .

5 -

6 -

7 .

8 -

9 .
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Detoxification schedule 2
Milligrama Day :

Milligrams

0
0

Milligrams

(')

1 Detoxification completed.

Detoxification Schedule S

Day : Milligrams Day :

1 20 43

15 15 50

29 10

Milligrams

5
0

Detoxification Schedule 4

Day:
1 _
15
29
43

Milligrams
30
25
20
15

Day:
57
71

85,

Milligrams

10
5
0

Day;

191

Maintenance Schedule 10
Day:

1 X mgs. 10.

2 X mgs. 11.

3 X+5 mgs. 12.

4 X+5 mgs. 13.

5 X+10 " 14.

6 X+10 " 15.

7 X+15 " 16.

8 X+15 " 17.

9 X+20 " 18_

X+20 mgs.
X+25 "
X+25 "
X+30 "
X+30 "
X+35 "
X+35 "
X+40 "
X+40 "

To 100 mgs. total or until otherwise stopped by adding 5 mgs. to dose every
other day.

Maintenance Schedule 11

Day:
1.
2.
3-
4.
5-
6.

Day:

-.X mgs.
..X mgs.
-X mgs.

-.X+5 mgs.
- X-i-5 mgs.
-.X+5 mgs.

7-
8__
9_-
10-
11_
12.

. X+10 mgs.
-X+IO mgs.
-X+IO mgs.
-X+15 mgs.
-.X+15 mgs.
.X+15 mgs.

To 100 mgs. total by increasing by 5 mgs. every third day or until stopped by
prescription.

Maintenance Schedule 12

Day:

1 X mgs.

8 X+5 mgs.

15 X+10 mgs.

Day:

22 X+15 mgs.

29 X+20 mgs.

Attachment Four

Statement of Responsibility for Take Home Medication

I, , understand that methadone is a powerful drug which

can seriously harm or even kill a person who is not on methadone maintenance.
For this reason, I agree to put my methadone bottle in a locked container, out
of children's reach. I also agree to tell my family how dangerous methadone can
be and take all necessary precautions to prevent its accidental use.

In addition, I understand that I must not lose, break or fail to return my
methadone bottle to the clinic or revert to drug u.se. If I do, I will not be able
to take methadone home but will have to I'eport into the clinic daily for at least
30 days.

Patient signature and date

Printed or typed name

ID number

Program name

NTAForm 22 (11-70).

Clinic administrator, piiysician
or nurse signature and date

192

ATTACHMENT- FIVE,

•■ I HI
E - <

ofo

PATIENT'S IDENTIFICATION

J: I

NARCOTICS TREATMENT ADMINISTRATION

CENTER ADDRESS

PATIENT'S SIGNATURE

ADMIN. BY (Sign Below)

METHADONE

COUNSELING

DOSAGE LEVEL

NARCOTICS TREATMENT
ADMINISTRATION

STATUS
□ hold □detox. □ MAINT. □abstinence □ SURV. ONLY

TESTS REQUESTED

COCAINE

AMPHETAMINE

BARBiTURATES

TEST RESULTS

^^^^y^,Lj.U^

''<M/////MyMmy/yM:/,ymA''/Z

OTHERS (Specify)

I I ALL TESTS NEC.

I I REPEAT

CHECK APPROPRIATE BOX

E SURVEILLANCE

-j I URINE

lETHADONE

COUNSELING

ATTACHMENT SIX

^ 5

UJ D

0 J

1 o
3 U

0 u.

•" o

UJ L>

a I-

1 o

u. UJ
O I

°^

< °

PATIENT'S IDENTIFICATION

1. PATIENT TRANSFERRED

FROM(Pf*>:irnt Cfnlot)

TO(New Ccntci)

2. PATIENT'S CLASSIFICATION (Check approptiale blocks) j

Participating }n Pvogram 1 ;'

Voluntarily withdrew from program a/rer completrng treatment

i
i

CENTER ADDRESS

DATE

involuntarily withdrew from program- incarcerated

Involuntarily withdrew from program-/josp/fa//>edor other medical reason

ST
5
cr

Disniisied from program -alcoholism oi drinking problem

COUNSELOR'S
SIGNATURE

Dismissed from program— bad conduct or disciplinary problem

Deceased

J ADMINISTRATOR'S SIGNATURE

Other (specify) i

t/J

(D O
•fi ^ ^

3 4- uj

< E

SI::

193

ATTACHMENT SEVEN

PATIENT'S IDENTIFICATION

DOSAGE LEVEL

NARCOTICS TREATMENT
ADMINISTRATION

PATIENT'S PROGRAM SPECIFICATIONS

1 I DETOXIFICATION SCHEDULE

1 ' '

CENTER ADDRESS ,,

DATE , ,

n MAINTENANCE SCHEDULE

n~]HOLD ' j

5
cr
0 ,

DATE OF PHYSICAL

r] OTHER MEDICATION

"■ DOCTOR'S SIGNATURE

QfHANGEOF MEDICATIONS 1

ATTACH>ffi:NT EIGHT

DIRECTOR'S DISCREPANCY NOTICE

PATIENT'S NArt

DATt

TO: The Center Administrator

FROM: Director, Narcotics

Treatment Administration

CE.^ER

1.0. NO.

PLEASE ADVISE WITHIN 24 HOURS, THE REASON(S)
FOR THE DISCREPANCIES LHLCXED BELOW.

1. MEDICATION

PERIOD COVERED

□ record not R£CEIVEO(nt» form 6) r]"0 RECORD CF PATIENT'S PHYSICAL EXAM. QoTHER (explain)

(lITA FORM 10)

QrECORD REC'D LATE(nt« form 6) QoOES NOT t€CT ftDICAL GUIDELINES

n NO RECORD CF OR'S PRESCRIPTION Q I (CONSISTENT WITH OR'S PRESCRIPTION

" — ' (nTA form 10) INTA FORM 10)

PERIOD COVERED

URINE ANALYSIS

PI HOST RECENT RECORD NOT REC'D (Submit nta form 6) jZI QUANTITY NOT SIFFIC lENTdjNs)

Q RECORD RECEIVED LATEInta form 6) LH CONSISTENTLY DIRTY (Th8 or i«re Tii*s)

3. CHANGE OF STATUS

PERIOD COVERED

NO ACTIONS INDICATED IN PAST TW0(2) WEEKS
(rJTA FORM 9)

QnO /CTIONS INDICATED IN PAST FOlf) WEEKSd.) (nta form 9)

PERIOD COVERED

COUNSELING

n NO CONTACT INDICATED IN PAST WEEK(mt« form 6) 0 NO CONTACT INDICATED IN THE PAST

(nta form 6)

□counselor's REPORT OVERDUE (Counselor's NA^c , )

{

I I TWO WEEKS
I I MONTH

5. SERVICE AT OTHER CENTER

NAf€ CF OTHER CENTER

DATE

PERIOD COVERED

Q NO REFERRAL INDICATED (nta form 9)

^ETHADONE DISBURSEMENT

TomniuFBEr

PERIOD COVERED

TOTAL A:iOUrn REPORTED DOES NOT AGREE WITH Tt£
AMOUHT DISBURSED IN TfC BOTTLE

AMOUNT OF DISCREPANCY (-HJR .)

SIGNATJiE OF THE DIRECTOR

DATE

TO: DIRECTOR, NARCOTICS TREATMENT ADMINISTRATION

CENTER AOnl'IISTRATOR'S REPLY(USE REVERSE SIDE IF NECESSARY)

SICNATlFE OF THE CENTER AOMI')ISTRAT0R

DATE

194

ATTACHMENT NINE

GOVERNMENT OF THE DISTRICT OF COLUMBIA
Narcotics Treatment Administration

PATIENT CONSENT FORM FOR RELEASE
OF TREATMENT INFORMATION

I hereby authorize the following person/agency:

Name

Address

Telephone

I vmderstancT'tEair'ohlyTnformation Central is authorized
to release this information. This consent form is void after

PATIENT SIGNATURE,
DATE

WITNESS

195

A.O. 202.1
Addendum
April 7, 1971
OD
Administration Order

1. Purpose

The purpose of this administration order is to provide additional clarification
for the medical and program guidelines as originally issued for the Narcotics
Treatment Administration programs and cooperating agencies.

2. Procedures

Anyone missing 3 days medication at any center is to have his medication dis-
continued until he sees the doctor at the center, at which time he will need a new
prescription signed by the physician. If a physician is not immediately available,
the patient may be given an emergency dose not to exceed 25 mgs. to hold him
until he can see the physician.

No new patient can be given a dose in excess of 50 mgs. on the first day of his
program, whether it is maintenance or detoxification, unless it can be verified
that he is being transferred from a maintenance program and is currently on a
higher dose.

[Exhibit No. 11(e)]

A Study of Narcotics Addicted Offenders at the District of Columbia Jail

(By Nicholas J. Kozel, Barry S. Brown, and Robert L. DuPont, Narcotics Treat-
ment Administration, Washington, D.C.)

(An acknowledgement of appreciation is made to Charles Rodgers, Superintendent of the
District of Columbia Jail, for his cooperation and assistance in this study and to the
research assistants for their unremitting effort to collect data under extraordinary
conditions. )

A study was conducted at the District of Columbia Jail between August 11 and
September 22, 1969, in an effort to determine the parameters of heroin use in the
District of Columbia. Findings of the study are based on responses to interview
schedules personally administered by a team of research assistants and the re-
sults of urinalysis conducted separately by the research assistants.

METHOD

Interview schedules were completed on an accidental sample of 225 of the resi-
dents present at the District of Columbia Jail during the time the study was con-
ducted. In addition, urine specimens were collected from 129 of those interviewed.
Urine specimens were collected from as many new offenders as possible at the
time of their admission. The research team subsequently attempted to intersnew
as many of these new admissions as they could reach — usually within the first
few days of incarceration.

To determine whether the sample interviewed was representative of the larger
offender population from which it had been drawn, comparisons were made on se-
lected personal and .social characteristics. Comparisons made on age, race, number
of prior commitments, and offense for which presently incarcerated indicated that,
in terms of the.se characteristics, the sample was representative of the District of
Columbia Jail population.

RESULTS

Drug use

Among the 225 offenders interviewed, 45 percent were identified as addicted to
heroin. Forty-three percent admitted using heroin and having been addicted to it.
An additional 2 percent of the total sample — 3 percent of the sample of urinal-
yses— reported never haviD<r used heroin or refused to answer the question con-
cerning lieroin use, but had positive urinalysis results for morphine and/or
quinine — the components of heroin (table 1).' Thus, 45 percent of all per.sons ad-
mitted to the District of Columbia Jail can be described as addicted to heroin.

Among nonaddicts, 22 percent stated they had u.sed drugs at some time in the
pa.st (table 2). Of these, most started out on marihuana. At the same time, almost

^ This veracity among narcotics addicts supports Ball's findings in his study of addict
interview responses. Ball, John C. "The Reliability and Validity of Interview Data Obtained
from 59 Narcotic Drug Addicts." The American Journal of Sociology, 1967, 72(6), 650-654.

196

half of the addicts stated that marihuana was the first drug they had ever used.
About a quarter of the addicts, however, started out directly on heroin (table 2a).

Cocaine. — The great majority of self-reported addicts — 85 percent — have used
cocaine, usually trying it for the first time after they had turned 20 years of age.
More than half of those who have used cocaine in the past admit to still using it.
At the same time, 29 jiercent of the nonaddicts who admitted using drugs liave
tried cocaine (tables 3, 3a, and 3b).

Marihuana. — Marihuana has been used by far more nonaddict drug users —
68 percent. — than any other drug. Similarly, 75 percent of the self-reported addicts
have used marihuana. Among addicts, around a third had used marihuana for
the first time before age 17. but when both groups are combined, 50 percent report
having used marihuana for the first time when they were older than IS years.
About half of the nonaddicts and a third of the addicts who had tried marihuana
in the past are still using it ( tables 4, 4a, and 4b ) .

Barbiturates. — Eighteen percent of self-reported addicts admit having used
barbiturates. Like marihuana, barbiturates were, for the most part, "first tried
after the user had reached 18 years of age. Five of the 17 addicts who have used
barbiturates state they are using them at present (tables 5, 5a, and 5b).

Methadone. — Street methadone has been used by 16 percent of self-reported
addicts. None of the nonaddict drug users report ever having used street
methadone.

Amphetamines. — Among self-reported addicts and nonaddict drug users, 18
percent mention having used amphetamines. Use of amphetamines begins at
about 18 and half of those who have used them in the past continue to use
them at present (tables 7. 7a, and 71)).

Heroin. — Though not addicted, four of the 28 nonaddict drug users have
used heroin. By definition, all of the addicts have used heroin. In terms of age,
half of the addicts had used heroin for the first time before they were 20 years
old. Indeed, 26 percent had used heroin by 17 ( tables 8 and 8a ) .

Heroin addiction

Withdrawal. — The overwhelming majority of self-reported heroin addicts —
88 percent — stated that they had experienced withdrawal symptoms (table 9).
At the same time, only 38 percent recall ever receiving treatment for their
addiction problem (table 9a ) .

Off drugs during past 5 years. — Eighty -five percent of addicts report having
been off the drugs for some period of time during the past 5 years (table 10).
The number of times drugs have been voluntarily or involuntarily given up
ranges from one to more than 10, with over half of the addicts claiming to have
been off drugs three times or less during the past 5 years ( table 10a ) .

Support of habit. — The average reported cost of a heroin habit is .$44 a day.
Not surprisingly, the majority of heroin addicts have resorted to crime as a
means of supporting their habit (table 11). Crime, hustling, and pushing drugs,
alone or in combination with legitimate employment are the usual ways in which
habits are supiwrted (table 11a ) .

Stop own drug use. — Eighty-eight i>ercent of addicts believe that they can
stop using drugs (table 12). A variety of ways of stopping drug use were men-
tioned including changing environments, methadone or other treatment, work,
and jail. However, 26 percent of those who believe they can stop feel they could
just stop without outside assistance, while an additional 11 percent either could
not answer or did not know how to stop their own drug use (table 12a).

Drug use among family. — There is reportedly little drug use among members
of the addicts' families — ranging from 5 percent among si>ouses to 10 percent
among siblings. At the same time, there is a relatively high incidence of don't
know/no answer responses to questions about family drug use (tables 18. 13a,
and 13b). This suggests that, while inclined to l>e candid about their own history
of drug use, addicts may be less than willing to revenl information about their
family which they feel would, in some way, place their family in jeopardy.

Drug use among friends. — The preponderance of addicts report that at least
some of their fHpnds usp drugs. Indeed, a third state that all of their friends
are drug u.sers, while 2 T)ercent deny having any friends who u.se drugs (table 14).

Age of drug users. — Slightly more than a third of the addicts reiwrt that most
heroin iisers today are between 16 and 25 years of age. At the same time, an-
other third either don't know or didn't respond lo the nuestion (table 15). Drug
use, according to a majority of the addicts, presently begins among youtlis between
15 and 17 years old ( table 1 5a ) .

Methadone treatment. — Eighty-six percent of self-reported heroin addicts have

197

heard of methadone treatment as a way of overcoming illegal drug use (table 16).
Of these, almost three-quarters believe methadone treatment is good without
qualification, while an additional 7 percent feel that, on the whole, it is good,
but still have some reservations about it (table 16a) .

Personal and social characteristics

Age and education. — About a third of addicts and nonaddicts are 21 years
old or younger and two-thirds are under 30 (table 17). More than 75 percent
of the two groups have had some high school education, and 25 percenit report
graduating from high school (table 18).

Parents. — Approximately 80 percent of addicts and nonaddicts claim to have
been reared by their biological parents (table 19). At the same time, a greater
number of addicts as compared to nonaddicts report that both of their parents
are stSll living (table 20).

Among those whose parent (s) are deceased, about 50 percent of the addicts
were less than 16 when one or both parents died, while about half of the non-
addicts were between 16 and 21 when death of parent (s) occurred (tables 20a
and 20b).

Siblings. — Compared to addicts, nonaddicts tend to have more brothers and
sisters. Thirty percent of nonaddicts have four or more brothers and 20 percent
have four or more sisters compared to 15 and 11 percent respectively for
addicts (tables 21 and 21a).

Religion. — Both addicts and nonaddicts are more likely to be members of
Protestant seots than other religious groups. At the same time, a significantly
greater number of nonaddicts compared to addicts report religious aflBliation
(table 22). Furthermore, while there was noticeably more frequent attendance
at religious ser\iees during childhood among both groups, significantly more
nonaddiots compared to addicts claim to attend services at present (tables 22a
and 22b).

Martial status. — The majority of both addicts and nonaddicts are single (table
23). Among those who are married, slightly more addicts report having been
married for 2 years or less (table 23a). Both groups have experienced a high
incidence of separation from their spouses — 60 percent on the average (table 23b).

Employment status. — Significantly more nonaddicts than addicts were employed
at time of arrest (table 24). The majority of both groups were employed by tht*
time they reached 18 years of age (table 24a) and the usual type of employment
for both groups is unskilled labor (table 24b) . More than half of both groups have
been employed at three or le.ss places during the past 5 years (table 24c).

Residence. — Neither group is very mobile. Twenty-three percent of the non-
addicts and 33 percent of the addicts have resided at the same home for the
past 5 years. Over 70 percent of the two groups have changed their residences
less than three times during the past 5 years (table 25). Further, about half
of both groups resided for more than 1 year at the home in which they were
living at the time of their arrest ( table 25a ) .

Income. — Almost two-thirds of addicts and nonaddicts supported themselves
financially at time of arrest. Twenty percent were dependent on their parents
(table 26). About half of both groups reported that the weekly income of the
home in which they were living when arrested was between $51 and $150 (table
26a).

City of Birth. — Significantly more addicits were born and spent most of their
childhood in large cities as compared to nonaddicts (tables 27 and 27a).

Military service. — Between 25 and 29 percent of the two groups served in the
military (table 28). Nonaddicts had slightly more years of service (table 28a)
and 70 percent of both groups, on the average, reported having had honorable
discharges (table 28b) .

Criminal offenses. — In terms of pre.sent offenses, addicts are charged with
more offenses against property and drug violations — 37 and 15 percent respec-
tively as comapred with 30 and 6 percent respectively for nonaddicts. Non-addicts
are charged are larceny and theft, while nonaddicts are not charged with any
addicts (21 percent). However, three of the four criminal homicides reported
were charged against addicts. The most frequent crimes with which addicts
are charge are larceny and theft, while nonaddicts are not charged with any
single offense with outstanding frequency ( table 29 ) .

198

CONCLUSIONS

Certain patterns emerge from the results of this study. One of the most
relevant is the alarmingly widespread use of heroin in the District of Columbia.
Forty-five percent of offenders entering the District of Columbia jail are heroin
addicts. Further, there is reason to believe that hard narcotics are l>pginning
to reach a younger population. Although addicts at the District of Columbia
jail started using drugs in their late teens or early twenties, drug use today is
starting at about 15 or 16 years of age. The profound implications of this problem
for society are apparent. Addicts must turn to antisocial behavior, at least in
part, to support their habit. And this deviant behavior will continue to increase
as a function of addiction.

Another important finding is the lack of difference between addicts and non-
addicts in the criminal justice system. It appears to be a widely held belief that
addicts belong to a subculture with its own unique membership characteristics
quite distinct from the nonaddict criminal subculture. However, the similarity
between addicts and nonaddicts in terms of personal and social characteristics
and, to some extent, drug use (marihuana) suggests that both addict and non-
addict offenders may. in fact, belong to a single subculture characterized by a
variety of illegal activties, one of which is use of hard narcotics.

Although, for the most part, addicts and nonaddicts share common character-
istics, there are a few areas in which they differ. For example, nonaddicts tend
to have more ties to the community — come from larger families and attend
religious services with much greater frequency — than addicts. These indica-
tions of a closer relationship with the community may, in effect, provide addi-
tional support which the addict finds lacking.

Addicts, on the other hand, appear to be more urban, having been born and
reared in large cities to a much greater extent than nonaddicts.

The results a' so point out a difference between addicts and nonaddicts in terms
of the offenses with which they are charged. This provides some support for the
idea that addicts do not commit crimes against people with the same frequency
as nonaddict offenders.

Contrary to the stereotype of an unstable, highly mobile personality, the nar-
cotics addict appears to be able to retain employment. A surprisingly high per-
centage of addicts were employed at the time of arrest and. indeed, almost half
of the addicts claim to have supported their heroin habit in part through work.
Further, adicts showed a certain stability of behavior — at least to thf extent of
not differing from nonaddicts — in maintaining themselves in the military.

One further point that deserves mention is the apparent interest that most
addicts have in stopping their own drug use. The great majority have been off
drugs at some time during the past several years. Most addicts al.so l)elieve.
realistically or not. that they can give up drugs on their own. In addition, even
before the city wide narcotics treatment program was imniemented in which
methadone was used as one technique of treating heroin addiction, most addicts
had heard about methaone. and a majority of these believe it was a good form
of treatment. This favorability toward methadone may provide a treatment
climate which could facilitate rehabilitation.

In conclusion, it should he mentioned that intensive research in narcotics addic-
tion and treatment has, in a sense, very recently begun. Very little seems to be
known about the addict. This study provides some basic descriptions of a specific
addict population. Hopefully, those findings will suggest new areas of research
aimed at combating the problem of heroin addiction in the community.

TABLE 1.— POSITIVE URINALYSES FOR MORPHINE AND OR QUININE AND SELF-REPORTED HEROIN DEPENDENCE

Urinalyses and self-reoorts:

Interview positive; urine oositive

Interview/ positive; urine negative

Interview positive; no urine

Interview negative; urine positive

Interview negative; urine negative...

Interview negative; no urine

Total 100 100

Addict

Non-

addict

Total

Number

Percent

Number

Percent

Number

Percent

42 .

10 .

44 .

4 .

73
52

125

100

225

100

199

TABLE 2.— SELF-REPORTED USE OF DRUGS

Addict

Non-addict

Total

Number Percent Number Percent Number Percent

Ever used drugs:

Yes

No answer

Total.

First drug of abuse:

Marijuana

Heroin

Cocaine __-

Other

No answer; don't know

Total

96
2

96
2
2 ...

28
97

22
78

124

55
44

100

45
23
13
3
16

125

4
2

1
4

100

61
14

225

60
26
14
4
20

100

124

100

TABLE 3.— PROFILE OF COCAINE USE

Addict

Nonaddict

Total

Number Percent Number Percent Number Percent

Ever used cocaine:

Yes

Total

(a) Age at 1st use of cocaine:

14 years

15years

16 years _

17 years _

18 years..-

19 years...

20 years

21 years or older

No answer; don't know

Total

(b) Presently using cocaine:

Yes

No...

No answer

Total

90
34

100

124

100

2
4
7
6
7
12
35
8

1 _

9 2

15 1

42 3

10 2

4
4

100 8

1
2
4
9
6
7

13
38
10

I
2

5
10
7
8
14
42
11

100

8 ---

100

56
23
21 ....

4 _

50
23
17

100

TABLE 4.— PROFILE OF MARIHUANA USE

Addict

Nonaddict

Total

Number Percent Number Percent Number Ferceil

Ever used marihuana:

Yes -.- 72

No 23

No answer.. 1

Total ___. 96

(a) Age at 1st use of marihuana:

13 years Of younger... 2

14 years 5

15 years 8

16 years... 8

17 years 6

18 years or older 34

No answer; don't know 9

Total....

(b) Presently using marihuana:

Yes

No answer... _

Total 72

100

75 19 68 91 73

24 9 32 32 26

1 1 1

100 28 100 124

2 2 2

7 5 5

11 I 5 9 10

11 1 5 9 10

9 2 11 8 9

47 11 58 45 50

13 4 21 13 14

100

31
47
22

9
7
3

47
37
16

31
41
19

100

200

TABLE 5.— PROFILE OF BARBITUARATE USE

Addict

Nonaddict

Total

Number Percent Number Percent Number Percent

Ever used barbituarates:

Yes -

No...

Total.

(a) Age at first use of barbituarates:

14 years or younger

ISyears...

16 years..

17 years

18 years or older

No answer; don't know

Total.

(b) Presently using barbiturates:

Yes

No. __

No answer..

Total.

1
27

4
96

106

100

124

100

1
1
1
1

12
1

10
2

1
1
1
1

12
2

TABLE6.— PROFILE OF STREET METHADONE USE

Addict

Nonaddict

Total

Number Percent Number Percent umber Percent

Ever used street methadone:

Yes _

No -

Total.

(a) Age at first use of street methadone:

18 years _

19 years

20 years

21 years or older

No answer ; don't know

Total.

(b) Presently using street methadone:

Yes...

No answer

Total.

15
81

16 ...
84

.........

""""ioo"

15
109

12
88

100

124

100

TABLE 7.-PR0FILE OF AMPHETAMINE USE

Ever used amphetamines:

Yes

Total.

(a) Age at 1st use of amphetamine:

16 years

17 years...

ISyears

19 years or older

No answer; don't know

Total.

(b) Presently using amphetamine:

Yes...

No answer

Total.

Addict

Nonaddict

Total

Number Percent Number Percent Number Percent

12
84

13
87

4
24

14
86

16
108

13
87

100

124

100

5
5
2

1
2
9
2
2

8 .
6 .
2 .

201

TABLE 8.-PR0FILE OF HEROIN USE

Addict

Nonaddict

Total

Number Percent Number Percent Number Percent

Ever used heroin:

Yes -

No..._

Total...

(a) Age 1st use of heroin:

14 years or younger 1 1

ISyears 5 5

16years 8 8

17years 11 12

ISyears 12 13

19years 11 12

20years 8 8

21 years 6 6

Over21 years 34 35

Total. 96 100

100

4
24

14
86

100
24

81
19

100

124

100

1
1
1

100

TABLE 9.-HER0IN WITHDRAWAL

Addicts

Number

Percent

Ever withdrew:

Yes

No answer; don't know

Total..

(a) Treatment for heroin addiction:
Yes..

No answer; don't know

Total

100

TABLE lO.-OFF DRUGS DURING PAST 5 YEARS

Addicts

Number

Percent

Off drugs:

Yes

No answer; don't know

Total

(a) Number of times off drugs during past 5 years:

4to5

6 to 10

More than 10...

No answer; don't know

Total

100

60-296 O — 71 — pt. 1-

-14

202

TABLE ll.-SUPPORT OF HEROIN HABIT

Addicts

Number

Percent

Ever commit a crime to support habit:
Yes

57
27
12

No answer

Total

100

(a) Usual way habit was supported:

Hustling (N =96)

55
45
42
27

Work (N =96)

Crime (N =96)

Pushing (N =96) ..

TABLE 12.-

-BELIEVE OWN USE OF DRUGS CAN BE STOPPED

Addicts

Number

Percent

Can stop:
Yes

1
8
3

No answer

Total

100

(a) Way in which own use of drugs can
Just stop

be stopped:

Change environment

Treatment; therapy..

Methadone

19
18
14

Work

Jail . .

No answer' don't know

Total

100

Addicts

Number

Percent

TABLE 13.-DRUG USE BY SPOUSE

Addicts

Number

Percent

Drug use:

Yes .

No answer' don't know

Total

100

(a) Drug use among siblings:
Yes

9
62

No ....

No answer; don't know

Total

100

(b) Drug use among other members of the family:
Yes:

Father - -- -.-

3
3
3

65
26

Mother

Other

No ...

No answer; don't know

Total

100

203

TABLE 14— DRUG USE AMONG FRIENDS

Addicts

Number

Percent

Drug use:
Yes:

All

Most

Some _

No answer; don't know.

Total

_ 100

100

TABLE 15.-

-AGE OF MOST HEROIN USERS TODAY AS REPORTED BY ADDICTS

Addicts

Number

Percent

Age:

Less than 10 years.

11 to 15 _

16 to 20 _

21 to 25... ._

26 to 30..

31 to 35

36 to 40

More than 40 years

No answer; don't know __

Total .

(a) Age at which most drug use presently begins as reported by addicts

12 years or younger..

13 _

15.

16 -

17.. _

18 years or older..

No answer; don't know

Total _

100

TABLE 16.-FAMILIARITY WITH METHADONE TREATMENT

Addicts

Number

Percent

Heard of methadone:

Yes

No answer

Total

(a) Favorability concerning methadone treatment
Believe methadone treatment is good:

Yes (unqualified)

Yes (with reservations)...

Don't know..

No answer

Total.... _

86
9
5

100

204

TABLE 17.-AGE OF ADDICTS AND NONADDICTS

Addict

16 to 17 _

18tol9 _ 16 16

20to21 14 14

22to23 7 7

24to25 _ 9 9

26to27 9 9

28to29. 9 9

30to31... _. 9 9

32to33 _ 4 4

34to35.. 4 4

36to37. _ .55

38to39 _... 2 2

40orolder 12 12

Total.. 100 100

Nonaddlct

Total

Number

Percent

Number

Percent

125

100

225

100

TABLE 18— HIGHEST GRADE COMPLETED

Addict

Nonaddict

Total

Number Percent Number Percent Number Percent

LessthanS 10 10 19 15 29 13

8 __._ __ 8 8 7 5 15 7

9 - 13 13 22 18 35 16

10 22 22 16 13 38 17

11 21 21 25 20 46 20

12 19 19 19 15 38 17

Some higher education 6 6 12 10 18 8

No answer 115 4 6 2

Total 100 100 125 100 225 100

TABLE 19.— REARED BY NATURAL PARENTS

Addict

Nonaddict

Total

Number

Percent

Nui

Tiber

Percent

Number

Percent

102

181

Yes

No answer.

Total

100

125

100

225

100

TABLE 20.-PARENTS LIVING OR DECEASED

Addict

Nonaddict

Total

Number

Percent

Number

Percent

Number

Percent

Living or deceased:

Both parents living

Father deceased _

Mother deceased

Both parents deceased

No answer, don't know

Total

(a) Age at time of mother's death

5 years or younger.

etc 15

16to21....

Over 21

No answer; don't know..

Total

(b) Age at time of father's death:

5 years or younger

6tol5_

16 to 21 ^...

Over 21.

No answer; don't know..

Total ._

100

125

100

225

100

205

TABLE 21.— NUMBER OF BROTHERS

Addict

Nonaddict

Total

Number Percent Number Percent Number Percent

Number:

0 18 18

1 21 21

? - 24 24

3. _._. 14 14

4.. _.- 9 9

5 3 3

6 _.__

7 _ 2 2

More than 7 _._ 1 I

No answer; don't know 8 8

Total ._ 100 100

(a) Number of sisters:

0 16 16

1--- - -- _.__ 28 28

2 22 22

3 14 14

4.. __ 5 5

5 3 3

6...

7 1 i

Morethan7 2 2

No answer; don't know 9 9

Total 100 100

125

TABLE 22.— RELIGIOUS AFFILIATION

100

Addict

Nonaddict

225

Total

100

Number Percent Number Percent Number Percent

Affiliation:

Protestant 43 43

Catholic... 24 24

Other 10 10

None _ 23 23

No answer; don't knowi

Total 100 100

(a) Childhood attendance at religious services:

At least once a week 82 82

Less than once a week 5 5

Notatall 12 12

No answer; don't know _ 1 1

Total 100 100

(b) Present attendance at religious services:

At least once a week 26 26

Less than once a week 10 10

Notatall 63 63

No answer _ 1 l

Total __.. 100 100

106

125

100

225

100

181

100

110

100

206

TABLE 23.— PRESENT MARITAL STATUS

Addict

Nonaddict

Total

Number Percent Number Percent Number Percent

Status:

Married

Single

Separated or divorced

No answer...

Total...

(a) Length of time married:

1 year or less...

2 years

3 to 4 years

5 to 6 years

7 toSyears

9 to 10 years.

More than 10 years

No answer

Total J

(b) Ever separated from spouse

Yes

No. -

No answer

Total

125

100

125

100

225

100

TABLE 24.— EMPLOYMENT STATUS

Addict

Nonaddict

Total

Number

Percent

Number

Percent

Number

Percent

Status:

Employed

117

Unemployed _.

103

No answer

Total _

100

125

100

225

100

(a) Age at which first started working:

15 years or younger

16 years

17 years

18 yea rs

19 years

20 years. . _

21 years or older

No answer; don't know

Total

100

125

100

225

100

(b) Usual level of employment:

Unskilled...

65
25
22

110
49
44
11

Semi-skilled..

Skilled

Other

No answer; don't know. . . .

Total :.

100

125

100

225

100

0 .

More than 5

No answer; don't know

Total _

100

125

100

225

100

207

TABLE 25.— NUMBER OF PLACES RESIDED DURING PAST 5 YEARS

Addict

Nonaddict

Total

Number

Percent

Number

Percent

Number

Percent

106

Number:

2 to 3

4 to 5 -

6 to 7 -..-

8 to 9 -

10 or more

No answer; don't know

Total

(a) Lengtti of time resided at home in which living
at time of arrest:

Less than 1 month _ _.

1 to 3 months

3 to 6 months

6 to 12 months

1 to 3 years

3 to 5 years

More than 5 years _

No answer, don't know..

Total _

100

125

100

125

100

225

100

TABLE 26— MAIN FINANCIAL SUPPORT OF PEOPLE IN HOME IN WHICH LIVING AT TIME OF ARREST

Addict

Nonaddict

Total

Number

Percent

Number

Percent

Number

Percent

Financial support:

Self

Parent(s)

Friends

Relatives .

63
21
6
4
2
1
3

63
21

1 .

144
46
8
9
6
1
11

Spouse

Other

No answer..

of home in which living

1
5

Total

100

125

100

225

100

(a) Total weekly income
at time of arrest:

$50 or less

$51 to $100

7
35
31
12

7
7
1
2
23

10
56
58
22
12
13
5
7
42

4
25

$101 to $150

$151 to $200 .

$201 to $250

$251 to $300

$301 to $400

More than $400

No answer; don't know

3
19

Total

100

125

100

225

100

TABLE 27.-SIZE OF CITY IN WHICH BORN

Addict

Nonaddict

Total

Number

Percent

Number

Percent

Number Percent

Size:

Large city (over 500,000)

72
6
7
4
1
1
9

62
6

15
5
4

49
5

12
4
3

134

Medium city (100,000 to 500,000) .

Small city (10,000 to 100,000)

Town (1,000 to 10,000)

Village _._ _

Farm _

No answer; don't know...

Total

100

125

100

225

(a) Size of city in which most of childhood was spent :
Large city (over 500,000) _

74
5
5
2

1
12

74
5
5
2

67
2

10
2
5

54
2

14
8

141

Medium city (100,000 to 500,000)

Small city (10,000 to 100,000)...

Town (1,000 to 10,000)

Village

Farm... _.

No answer; don't know

Total...

100

125

100

225

208

TABLE 28.-MILITARY SERVICE

Service:

Yes

No answer

Total

(a) Years in military service:

1 year

2years

3 years

4 years

More thaa4 years

No answer _

Total

( b) Type of military discharge:

Honorable

Dishonorable

Medical

General.. ..-

Other.

No answer; don't know

Total _.

Addict

Nonaddict

Total

Number Percent

Number

Percent

Number

Percent

161

100

125

100

225

100

4 .

"l"

.....
8

1
4
4

100

TABLE 29.-OFFENSE FOR WHICH PRESENTLY CHARGED

Addict

Nonaddict

Total

Number Percent Number Percent Number

Percent

Offense:

Larceny; theft 21 21

Drug law violation 15 15

Robbery 10 10

Possession of implements of crime 5 5

Burglary 6 6

Receiving stolen property _ 3 3

Carry/possess weapon 5 5

Housebreaking

Assault (other than aggravated) 5 5

Soliciting (for lewd and immoral purposes) 4 4

Criminal homicide 3 3

Forgery; counterfeiting... 3 3

Fraud; embezzlement 2 2

Autotheft 2 2

Armed robbery 1 1

Bank robbery 2 2

Disorderly conduct; drunkenness 1 1

Escape 2 2

Destroying private properly

Assault (with a deadly weapon) _.

Offense against family. . _

Traffic violation. 1 1

Obstructing justice

Parole/probation violation 1 1

Unlawful entry.... 2 2

Resisting arrest

Sex offense

Manslaughter

Gambling

Contempt

Civil action

Ball Act

No answer; don't know 6 6

Total _ 100 100

25
5

7
2

14
10
11
2
6
2
6

125

100

225

100

(Thereupon, at 2:45 p.m. the hearing adjourned, to reconvene to-
morrow, April 28, 1971, in room 2253, at 9 :45 a.m.)

NARCOTICS RESEARCH, REHABILITATION,
AND TREATMENT

WEDNESDAY, APRIL 28, 1971

House of Representatives,
Select Committee on Crime,

Washington^ D.C.

The committee met, pursuant to notice, at 10 :00 a.m., in room 2253,
Ray burn House Office Building, the Honorable Claude Pepper (chair-
man) presiding.

Present : Representatives Pepper, Waldie, Brasco, Mann, Murphy,
Rangel, Wiggins, Steiger, Winn, Sandman, and Keating.

Also present: Paul Perito, chief counsel; and Michael W. Blom-
mer, associate chief counsel.

Chairman Pepper. The committee will come to order please.

The Select Committee on Crime today continues its hearings into
what science and medicine can do to help us fight heroin addiction in
the United States.

Yesterday, we heard impressive testimony from Dr. Frances Gear-
ing of New York and Dr. Robert DuPont of the District of Columbia
on the effectiveness of methadone programs.

Today we are continuing our examination of methadone with testi-
mony from Dr. Jerome Jaffe, director of the Illinois Drug Abuse
Program.

Dr. Jaffe was originally scheduled to testify yesterday, but was
kind enough to stay over until today as we ran behind schedule be-
cause of several votes on the floor.

We will also hear testimony today from Dr. Harvey Gollance, as-
sistant medical director of Beth Israel Medical Center in New York.

Both Dr. Jaffe and Dr. Gollance have had wide experience in the
administration of methadone maintenance programs.

We also have with us today Robert F. Horan, Commonwealth at-
torney for Fairfax County, Va., who will tell us about the special
drug-abuse problems of his suburban county.

We will also hear from Dr. Daniel Casriel about a new treatment
program for heroin addicts that employs a rapid-acting detoxification
drug.

And, finally. Dr. Gerald Davidson, of Boston City Hospital, will
explain the workings of his program.

We hope that the information we receive from these witnesses and
others yet to appear will help us formulate recommendations to the
Congress on what the Federal Government can do to fight addiction, in
addition to what we are now doing.

(209)

210

The committee is pleased to call now Dr. Jerome H. Jaffe, a dis-
tinguished doctor and the director of one of the Nation's largest drug-
abuse programs.

Dr. Jaffe is associate professor of psychiatry at the University of
Chicago, and director of the drug abuse program of the Illinois De-
partment of Mental Health.

Dr. Jaffe holds both a bachelor's and master's degree in psychology
from Temple University and an M.D. from the Temple University
School of Medicine.

He has been the holder of a U.S. Public Health Service Post Doc-
toral Fellowship in Pharmacology and has twice received the U.S. Pub-
lic Health Service Career Development Award.

Dr. Jaffe is a member of numerous scientific and honorary organi-
zations. He is a member of the editorial board of the International
Journal of the Addictions; a member of the Review Committee of
NIMH's Center for Studies of Narcotics and Dangerous Drugs; a
consultant to the Illinois Narcotic Advisory Council and the New
York State Narcotic Addiction Control Commission. He also serves
as secretary of the section on drug abuse of the World Psychiatric As-
sociation; a consultant to the Department of Health, Education, and
Welfare; and special consultant to the World Health Organization's
Expert Committee on Drug Dependence.

He is also the author of numerous articles on drug addiction.

Dr. Jaffe, we are indeed pleased to receive your testimony today.

Mr. Perito, will you inquire ?

Mr. Perito. Thank you, Mr. Chairman.

Dr. Jaffe, I understand that you have a prepared statement; is
that correct ?

STATEMENT OF DR. JEROME H. JAITE, DIRECTOR, ILLINOIS

DRUG ABUSE PROGRAM ^

Dr. Jaffe. That is correct.

Mr. Perito. Would you care to present that to the committee ?

Dr. Jaffe. Yes. I would like to comment briefly on four areas re-
lated to the problem of narcotics addiction and drug abuse :

First. The spectrum of treatment services required to treat narcotics
users, and our experiences in the State of Illinois in developing a
multimodality program for delivering such services.

Second. A progress report on acetyl-methadol, a drug that we be-
lieve may have significant advantages over methadone in the treatment
of heroin users.

Third. Our current estimates on the effect of treatment in reducing
antisocial activity.

Fourth. My own views on the kinds of research that will be re-
quired if we are to avoid another pandemic of drug use similar to the
one we are now experiencing.

1 Subsequent to Dr. Jaffa's appearance before the committee. President Nixon, on June 12,
1971, named Dr. Jaffe as his chief consultant on drucr abuse and drnp dependence and
proposed his name for consideration by the Senate as Director of the President's proposed
Special Action OflSce on Drug Abuse Prevention.

211

In the State of Illinois our efforts to develop treatment programs
began in 1966. Our approach to treatment was based on a very clear
set of premises and principles :

(1) Narcotic users are a heterogeneous group requiring different
treatments.

(2) To determine which treatments were most appropriate for a
given community required a community diagnosis.

(3) Treatment programs should be located in the communities
where patients lived.

(4) No program, no matter how sound it might appear to be theo-
retically or how appealing it was emotionally, would be continued
unless objective evaluation revealed it to be effective and to justify
the expenditure of public funds.

Initially, our program could be called a controlled comparison of
several different approaches, somewhat competitive, but friendly. We
developed a therapeutic community — Gateway Houses — modeled after
Daytop Village. We explored the use of narcotic antagonists such as
cyclazocine ; we developed halfway houses, a specialized hospital unit ;
and we used methadone for maintenance at both high doses and low-
doses.

Later we began to wonder why it was necessary to have a separate
unit for each approach. It became obvious that such separatism was a
relic of old rivalries and philosophical disputes that had no place in
a scientifically run and evaluated program. With some effort we were
able to get most of our units to offer all of the available approaches in
a more or less eclectic fashion.

In other words, at a single facility a patient could participate in a
methadone maintenance program, later withdraw, live in a residential
self-regulating community, reenter the community at large on an
abstinent basis, or elect to take cyclazocine and in the event of a
relapse, move back into a residential facility, or if he was holding a
job merely start again on methadone on an ambulatory basis. He
rnight then wait for a number of months — until it was his vacation
time — move into the facilities and then withdraw from methodone.

Not every unit is able to sustain specialized treatment services. For
example, we have one unit under the leadership of Dr. John Chappie
that specializes in the care of addicts with serious medical problems,
alcoholism, psychosis, and pregnancy. Yet this unit serves the entire
network and a patient who needs such treatment is merely transferred
without any interruption of treatment.

We believe that to reach the majority of addicts it requires more
than one approach or modality. We also believe that we have dem-
onstrated that all of the modalities can be accommodated within a
single administrative structure. The advantage to this approach is
that program planning and expansion can then be based on the results
of a fair and uniform evaluation system imposed by the administra-
tive structure rather than by emotion, rhetoric, and a political trial
at arms in the lists of the mass media. This kind of eclectic program
has come to be called the multimodality approach.

Currently lodged in the department of mental health and operated
with the cooperation of the University of Chicago, the program con-

212

sists of a network of 21 geographically distinct facilities across the
State serving more than 1,600 narcotics users.

Our present primary goal is to eliminate the waiting list so that
every patient who seeks treatment can get it immediately. We have
enjoyed the full support of the Governor, the legislature, and the
department of mental health. We should reach our primary goal with-
in the next 6 months.

11.

Almost from the beginning of the work with methadone, it was
obvious that if we expected patients maintained on methadone to lead
normal, productive lives it would be impossible to demand that they
come to a clinic every day in order to ingest their medication under
supervision. Eventually patients would have to be permitted to take
their medication home, and although we might hope that 95 percent
of the patients would not abuse this privilege, it would be naive to
hope that there would not be a small minority who would give away
or sell their prescribed medication. Among the potential solutions
to this problem would be a longer acting methadone-like drug.

In 1966, I proposed to study one such substance, acetyl-methadol,
but the project was shelved when I moved from New York to the
University of Chicago.

After a 3-year delay we resurrected the project and last year my
colleagues and I reported that acetylmethadol seemed to be as effec-
tive as methadone in facilitating the rehabilitation of heroin addicts.
Advantages includes its longer duration of action and its lower abuse
potential. Its longer duration should also mean reduced program oper-
ating costs since, obviously, you don't have to give out the medication
every day, but need only give it three times a week. Several months
after our first report, one of my collaborators. Dr. Paul Blachly at
the University of Oregon, sent us a confidential report in which he
observed some advei-se side effects with 1-acetvl-methadol.

By that time our group, including Drs. Charles Schuster, Edward
Senav, and Pierre RenauU had alreadv repeated our controlled dou-
ble-blind studies and had found no such side effects ; since that time
we have carried out still additional studies — so that our total experi-
ence includes well over 75 patients studied for at least 4 months. Thus
far our conclusions are the same — acetyl-methadol is as effective as
methadone.

I want to caution, however, tliat we have not used very high doses.
We have used it primarily and solely in males and we cannot be
certain at this point that at such higher doses we would not see un-
wanted effects.

III.

From the bejiinning of our program one of the criteria by which
we measured effectiveness was the extent to wliich treatment reduced
antisocial behavior. We have done at least four separate studies in
which we have compared the &t;lf- reported arrest rates of patients
prior to treatment and their arrest rates during treatment. In every
one of these studies we have observed a very substantial drop in the
arrest rates. In some instances the rates were reduced to one-half of
the pretreatment rate. In others, the rates were reduced to one-third

213

of the pretreatment rate. Until recently, we were unclear about how
to evaluate these results.

First, they are considerably less dramatic than those reported by
other workers. However, this could be due to our policy of taking
all applicants regardless of our estimate of how well they will do.

But second, for technical reasons, we were unable to examine the
actual arrest records of our patients, but were forced to rely on their
own reports to our legal unit. The only penalty for a failure to report
an arrest was that if it was later reported the legal unit would offer
no assistance with respect to that arrest.

More recently our program wrote a contract with the University of
Chicago Law School to conduct an independent assessment of the
impact of treatment on crime.

Mr. H. Joo Shin and Mr. Wayne Kerstetter were able to obtain
the arrest records of a sample of a little over 200 of our patients.
We then gave them access to all of our data. Their findings are still
being analyzed, but thus far they have found that official arrest rec-
ords do not record all of the arrests that our patients have had.

The study conducted by the University of Chicago Law School re-
vealed that prior to treatment this sample of patients had recorded on
their arrest records approximately 84 arrests per 100 man-years ; dur-
ing treatment, they accumulated only 31 arrests per 100 man-years.
Depending on how you want to calculate the percentage, this would
be viewed as a 61-percent reduction in arrest rate. Self-reported data
indicated that prior to treatment our patients had 148 arrests per 100
man-years. After treatment the arrest rate was 76 arrests per 100
man-years.

Thus, it appears that whether we use arrest records or patients self-
reports, arrest rates decrease dramatically. We do not have at present
a more detailed qualitative analysis of the change, but we suspect that
the crimes committed by patients in treatment are less impulsive and
more benign.

IV.

Lastly, we come to research :

It may be that I am too close to the issue to see it in perspective. To
a certain extent I consider myself a displaced person.

I left my laboratory and my research in order to develop a much
needed program in the State of Illinois and I look forward to returning
to full-time research.

The projects that I personally think deserve high priorities are :

(1) Further studies on the use of antagonists in facilitating the
withdrawal from methadone and in treating young people who have
begun to use heroin but have not become physically dependent. We
need to develop long-acting forms of nontoxic antagonists.

(2) An expanded investigation into the safety and utility of acetyl-
methadol and similar agents.

(3) The development of a system under the aegis of a health-care
authority for monitoring trends in drug use and addiction so that we
can mobilize earlier and more rationally to abort epidemics.

(4) Experiments to determine whether early intervention can abort
a microepidemic.

(5) Further studies on the natural history of the drug-using syn-
dromes; for example, we still do not know how many individuals stop
using various drugs spontaneously.

214

(6) Basic studies on the nature of the biochemical events involved
in tolerance and physical dependence.

Research requires people. It is simply inadequate to make money
available and expect that trained and competent researchers -will ma-
terialize from the ether. These individuals require support before they
are ready to conduct their own research and not all of those who re-
ceive such support will develop into able researchers. Thus, some sup-
port for training of new researchers or the retraining of researchers
from other fields is a prerequisite to a long-run attempt to conduct the
research I have described.

Thank you.

Chairman Pepper. That was a very able and comprehensive state-
ment. Dr. Jaffe.

Mr. Perito, do you have any questions ?

Mr. Perito. Thank you, Mr. Chairman.

Dr. JafFe, you started the program in Illinois in 1967 ?

Dr. Jaffe. Well, the legislature passed the appropriations bill and
it was signed in August of 1967. It took us a number of months to find
out how to use that appropriation because we were an entirely new
agency in a sense.

We took the first patient, under the aegis of the Department of
Psychiatry of the University of Chicago in January 1968, and that
began in my own office at the university. We sort of got started in an
unusual way.

Mr. Perito. You have gone from one patient to 1,590 patients from
January 1, 1968, up until the present time ?

Dr. Jaffe. We have at least doubled our patient load every year, and
intend to double it again this year. It is, we think, a very orderly rate
of growth.

Mr. Perito. Does your program or programs, rather, have a waiting
list at the present time?

Dr. Jaffe. Yes ; it has had a waiting list from the first day that we
took in the first patient. No matter how fast we expand, we have al-
ways had people waiting for treatment.

Mr. Perito. Your program is the largest in Chicago ; is that correct ?

Dr. Jaffe. Yes.

Mr. Pepito. Are there other large programs working in conjunction
with yours ?

Dr. Jaffe. Well, we have no mechanism for monitoring the size of
other programs. Unofficially, I think the largest program that does
not come under our aegis has 50 or 60 people.

Mr. Perito. Do you receive any Federal moneys for your program ?

Dr. Jaffe. There is one grant from the National Institute of Mental
Health to the University of Chicago.

Mr. Perito. Is this a research or a service grant ?

Dr. Jaffe. There is a service grant.

Chairman Pepper. How much Federal assistance do you receive?

Dr. Jaffe. The first year it was about $450,000 to $500,000. It was
a matching grant. It has decreased by 10 percent each year thereafter.

Mr. Perito. What do you figure the cost is, per patient-year, to iim
your program at the present time ?

Dr. Jaffe. Well, I can give you some exact figui-es, but I would
like to give you some context in which to put them.

215

About 20 percent of our patients are living in a residential setting.
At present, we use no traditional hospitals at $80 per day, but we
have developed more efficient — and we think more rational — ways of
handling patients who are drug abusers, since for the most part, cor-
rectly handled they are not acutely ill. Our residential settings still
cost us about $10 to $12 per patient per day, or $3,500 per year.

Our outpatient methadone program costs between $800 and $1,500
per patient per year.

Again, I give you this range because the longer somebody is in
treatment, if they remain continuously in treatment, the less costly it
is to treat them. Once they become stabilized they get a job and they
are functioning reasonably well.

At that stage, it does not take as much personnel or staffing to main-
tain that person in a functioning state. So that for a patient in the
early stages of treatment, you have to have more input. As our pro-
gram has matured, our outpatient cost per patient have actually gone
down in spite of inflation.

Now, if you want an overall cost for treating 1,600 people with the
research we have conducted, with our evaluation with our equipment
costs, the cost is a little over $2.4 million to treat 1,600 people.

Again, I caution you that we only reached 1,600 January 1, so you
are going to look at a mean patient load of about 1,400 over an entire
year.

In a program that is expanding it is more rational to look at the
projected cost when it stabilizes. At that point we expect that resi-
dential costs will be in the neighborhood of $3,000 to $3,500 per patient
per year, and outpatient costs will be about $1,200.

Mr. Perito. Do most of your funds emanate from the State of
Illinois?

Dr. Jaffe. The State of Illinois.

Mr, Perito. Do you receive any money for your program from the
University of Chicago ?

Dr. Jaffe. Only to the extent that the University of Chicago makes
commitments to faculty people and provides fringe benefits to those
faculty people, and these benefits that are very difficult to charge to
grants. In that sense we are supported primarily by the Federal
grant and the State of Illinois.

On the other hand, we sort of cannibalize a lot of the brainpower
at the University of Chicago and have no way of compensating them
for the unofficial consultation time and the time that we take up in
trying to plan strategy.

Mr. Perito. Doctor, how large is your staff at the present time,
that is your full-time staff ?

Dr. Jaffe. Well, there are approximately 135 total State positions
at this time. At the university there are perhaps 40 positions. Our
program was designed to maximize where possible community par-
ticipation and the co-opting of whatever community resources could
be brought to bear on this problem. Since there is a great reluctance
of community people to donate their time to the State, we arrange to
contract with specifically developed not-for-profit corporations to op-
erate certain components of this program. Although we evaluate them
and although we consider them operating arms of the program, they,

216

in fact, constitute autonomous or semiautonomous not-for-profit
corporations.

For example, Gateway Houses Foundation, which now runs three
residential facilities for young polydrug users and heroin users, oper-
ates on a contract with us and Gateway, I believe, employs 18 staff
people.

We have several other small organizations that are contracting with
those.

I would guess, in the aggregate, their staff may come to a total of
perhaps 30 people. So that if you want to total it all- up it is perhaps
about 220 people, give or take a few, to take care of this patient load.

Mr. Perito. Doctor, in your prepared statement you mentioned the
use of acetyl-methadol. Do you foresee that this long-lasting drug will
someday be a replacement for methadone?

Dr. Jaffe. Not entirely as a replacement for methadone. Any new
drug has its advantages and disadvantages.

First, I would like to emphasize that acetyl-methadol requires fur-
ther study. It may very well be that an attempt to use it at much
higher doses would cause some side effects. Furthermore, it is a drug
whose primary advantage is its long duration of action. This means
that it is a drug that can be given three times a week. No drug need
be taken home and therefore no drug can be illicitly diverted. It has
its advantages.

Mr. WiGGixs. Doctor, who developed this drug ?

Dr. Jaffe. This drug has been around since the 1950's. It was origi-
nally developed by Merck, tested at Lexington, but because it was so
long acting there was no further use for it in medicine. I was about
to say its advantage turns out to be its disadvantage. Many people are
not familiar with a drug that should not be given every 24 hours.
If you give it every 24 hours you get cumulative toxicity, the drug
lasts for several days, so that you have some overlap. Before this drug
can be widely used it will take an educational program.

Mr. Wiggins. You make an interesting point, and that is drugs that
are really effective sort of price themselves right out of the market,
don't they, because there is no longer a need for them if they solve
the problem that they are created to solve? Is that really what you
are saying here about this, that it was so effective that there was no
market for it ?

Dr. Jaffe. No; I am saying it was tested as an analgesic agent, a
painkiller, and in some instances people were unaware that this was
a drug that should not be given every day. When they gave it every
day some patients developed cumulative toxicity. In effect, by taking
it every day they received overdoses. This made it virtually useless
as an analgesic. It was just too tough to use.

Mr. Wiggins. This drug was developed by a private pharmaceu-
tical house ?

Dr. Jaffe. That is correct.

Mr. Wiggins. For sale for profit, I take it ?

Dr. Jaffe. It never reached the market in any meaningful way.

Mr. Wiggins. Are you satisfied that we can or should rely i:)rimarily
on the private researchers and pharmaceutical houses to develop a
drug that you may need ?

Dr. Jaffe. No.

217

Mr. Wiggins. "\Yliere else is it being done or should it be done ?

Dr. Jaffe. Well, my experience has been that we do not have an
effective mechanism for developing drugs which don't have a poten-
tially significant commercial market. Drug houses do not want — and
at least in my own experience — to develop drugs which have no
market, utilizing their own resource and their own personnel and their
own laboratory facilities.

On the other hand. I think we have precious little in the way of that
kind of resource within the public sector. Generally, universities are
not in the business of developing drugs.

Mr. WiGGixs. What suggestions might you make to the committee
if we are interested in encouraging the development of such drugs?

Dr. Jaffe. Well, I am not sure that I know enough about the devel-
opment of pharmaceutical preparations to make really meaningful
suggestions on it. I suspect there is some difficulty with respect to
patent problems. As soon as you give subsidies to a commercial or-
ganization, it then loses the possibility of distributing and marketing
that product for profit.

Mr. Wiggins. Well, could it be done alternatively or together at the
National Institutes of Health or at universities operating under
grants ?

Dr. Jaffe. I think it could be, but traditionally universities have
not been in the drug development business and it would mean think-
ing about what would be necessary to develop that capacity within
a university. J

The difficulty with many universities, at least until recently, is
that Govermnent encourages universities to apply for grants that
run for 3 or 4 years. The university recruits people and brings them
from wherever they were to the university. Their families are there.
And then the grants run out. The Government just says, well, we have
other priorities now. The university is left with the problem of staff
people who nobody wants any more. They are surplus. This is a hu-
man problem.

If the university doesn't teach the development of pharmaceutical
products, then, you know, it is very difficult to get it involved in de-
veloping this kind of thing.

There are, you know, schools of pharmacy, but whether or not they
are in the business of developing drugs, I can't say. The development
of new pharmaceuticals is npt^^y area^of expertise.

Mr. Wiggins. All right. ' -v ...^ ., ^ r ( ^ ■• r^^ ^

Chairman Pepper. Excuse me;"^,, ^.

Apropos to what Mr. Wiggins was asking you, the suggestion was
made the other day that it might be possible for the U.S. Government
to give grants to drug houses to carry on approved research in areas
where the Government desired such research be carried on, with the
understanding that if the company ever profited from the distribu-
tion of that drug, the United States would get its money back, and in
that way you would allow the company to retain the ownership of
the patent while reimbursing the Government should the research
produce a drug that is economically profitable. ,

Dr. Jaffe. That sounds like a very creative approach to me. I won-
der whether or not it can be accomplished. Certainly it is the first
time I have heard that suggestion. I know it has been a stumbling
block for most pharmaceutical houses.

60-296— 71— pt. 1 15

218

Chairman Pepper. Mr. Perito?
;; Mr. Perito. Thank you. Mr. Chairman. I have a couple of more
questions along that line for Dr. Jaft'e's consideration.

You had mentioned earlier during staff interviews that one of the
problems was in developing new research techniques involving possi-
ble development of antagonists that researchers become terribly spe-
cialized, but then when the problem is solved there is no need for them
any longer.

I wonder, could you expand upon this for the committee's benefit?

Dr. Jaffe. Yes; my point was simply that I think the situation is
somewhat analogous to the space program. If Government decides it
has a priority and wants to have a crash program, we can give out a
great deal of money and get people to drop a secure position where they
are teaching something or doing research on something which has
long-range value. Those people come into the field and they get in-
volved in the crash progi'am. As soon as the problem is solved, they are
out of business, and it is a human problem. I think it causes some re-
luctance for the best people to drop their work and get involved in it.

What you often get with this kind of crash interest is that you move
marginal people who haven't done well in more traditional fields than
this, which is precisely what won't get the job done. I have no specific
suggestions as to how to get the job done. I think it remains a problem
for Government to examine what it does about its human excess bag-
gage, particularly when that excess baggage turns out to be its best
brainpower that it recruits into solving public problems and then
abandons.

I can say for myself that at this point I would have to stop for a
number of months to review the literature, to prepare a grant applica-
tion, to get caught up with a research field in order to get a grant.
Since I moved into the public service sector in order to develop a
delivery system that made use of known research which existed in
1967 and 1968 I, at least, have a university base. Other researchers
may not have such an affluent base — I am not sure our university is
affluent — but at least universities are willing to make that commit-
ment of saying, "You may now sit back and get caught up with your
own field in order to compete for a grant."

This is the difficulty. You move people into one thing, then you want
them to switch. Nobody supports them during that interval while
they are trying to reacquire the tools and get caught up with the tech-
nology in order to compete for other grants.

We certainly have gutted the universities in many respects with
respect to their capacity to support people. They are very dependent
on research grants. When these things are cut back they have no way
of supporting those people who then are looking to find out what are
the new areas that are of interest to the public.

Mr. Perito. Have you found an appreciable difference on your crime
studies and the efficacy of your program in reducing crime or anti-
social behavior? Have you found a principal difference betAveen the
arrest records that you have checked, and the actual instances of crimi-
nal behavior that you have found out through interviews with addicts?

Dr. Jaffe. Well, I can say that our interviews with addicts indicate
that a great deal of crime occurs that is not reflected in an arrest. It is
a very interesting kind of thing. 'V^Tien we establish rapport with

219

somebody who, almost as a professional, engages in antisocial activity,
they will be very honest with you.

We have seen that when we get people into treatment, even A\-hen
they don't give up their antisocial activity entirely in the early months
of treatment — and get a legitimate paying job — their antisocial activity
still drops dramatically. They may not be arrested at all, yet we know
they are committing crimes. Nevertheless they are committing them
at half the rate they were committing thom. So that sometimes you
can get a great deal by talking to people that the arrest records will
not reveal.

The arrest records are only a very approximate index of what is
actually happening. There are discrepancies and they go in both direc-
tions. Sometimes people who commit virtually no ciime manage to
get arrested for some charge anj^way, and somebody else who is more
skilled continues to engage in antisocial activities for long periods and
is not arrested at all. We have seen both of these kinds of things go on.

Mr. Perito. Do you regard the coiicept of narcotic antagonists like
cyclazocine and naloxone as a hopeful aiea in multimodalit}' approach '{

Dr. Japfe. Do I regard the concept of narcotic antagonists as a hope-
ful area ? The answer is that I do.

HoAvever, as I said several 3'ears ago, it is quite clear that in order
to be effective in treating narcotics users a more appropriate form of
narcotic-antagonist will be required. We will require an antagonist
with minimal side effects that can be given in a way that will produce
a blockade of narcotic effects for at least several days. Unlike metha-
done, patients don't want to come back to a clinic every day just to
take a drug that blocks narcotic effects.

Some will. Some will for a number of months, but for the most
part, after a few months they are convinced they don't need the an-
tagonist any more, so they stop.

Chairman Pepper. Excuse me a moment.

The effect of this antagonist drug is to prevent them from getting
any sensation of satisfaction or euphoria from the taking of heroin?

Dr. Jaffe. That is correct.

Chairman Pepper. Now then, could you add to that drug the quality
of making the taking of heroin, again within a reasonable time, repul-
sive to the system; that is, causing a reaction of an unfavorable
character?

Dr. Jaffe. I am not sure that we have such a drug, nor am I really
certain that it would be useful. It would be interestmg if we had one,
but you see, they do have something comparable to that in alcoholism
with Antibus. and the results have not been overly dramatic. If the
revulsion reaction is severe enough it may be endangering somebody's
life and you have an ethical question.

The antagonists have the advantage that you can perhaps persuade
somebody to become involved with the antagonists, because it will not
hurt him if he takes a narcotic. It merely blocks the effect.

Obviously, what it does not do is in any way allay this kind of
narcotic hunger, this craving that some addicts seem to feol when
they are not actively using or during the first year or so after they
stop taking narcotics.

I want to get back to your question about naloxone and cvclazocine.
Cyclazocine I think we have explored. It is a difficult drug to use. It

220

is not a very forgiving drug. Its side effects require that the treaters
have a considerable degree of skill. It still lasts only 24 hours. Given
the effort required and given the level of patient acceptance, I don't
think cyclazocine is a drug that in its present form we can hope to
see widely employed.

Naloxone is a very promising substance, theoretically, in that it has
no side effects at all. For most people it is entirely inert. The problem
is that it is not very effective orally and it is short acting. Its cost is
such that even if you wanted to take it every day in huge quantities, it
would probably cost as much as the heroin habit that you are trying
to treat. Therefore, naloxone in its present dosage form, to me, is not
a very useful or a hopeful approach. ■ r ■

I might say that our hope lies with the entire family of narcotics
antagonists, and there are literally dozens that could be investigated,
one of which I am sure will be extremely potent, orally effective, and
have minimal side effects.

If that then proves to be promising it could be converted into some
kind of dosage form that might be effective for at least several days
or weeks.

This is a matter of product development. I am sure it can be done if
people are willing to put the effort into it.

Chairman Pepper. And the money.

Do you think it would be in the public interest for the Federal Gov-
ernment to expand its research funds to encourage the appropriate
people to develop those leads that you are talking about ?
o Dr. Jaite. I think if we do not look into them we will be remiss.

Chairman Pepper. Mr. Blommer, do you have any questions ?

Mr. Blommer. Thank you, Mr. Chairman.

Doctor, I believe Dr. Dole of New York has said he believes that
about 25 percent of the heroin addicts in New York would benefit from
methadone maintenance. I wonder if you could comment on that state-
ment and tell the committee what type of heroin addict you believe
should be put into a methadone-maintenance-type of program ?

Dr. Jaffe. Well, I will comment first on the 25 percent. I don't know
how Dr. Dole obtained his figure, but we came out with almost the
same figure, based on a very empirical 2-year study of heroin users in
the Chicago area. ^

In other words, we admitted everybody who came. If you came to
the door, you were admitted. We thought, based on epidemicologic
studies in the commounity, that about half of known active narcotics
users would seek treatment, and, of those, over tlie long run about lialf
would obtain substantial benefits. So half of half is 25 percent. This
is based on or data of several years and several thousand patients.

What kind of patient would benefit is much more difficult to answer:,
because it is very hard to predict. ^ - '

Mr. Wiggins. I^et me interrupt, because I want to get somethilig^^^
my mind. > i ■ m

Dr. Jaffe. Yes, sir.

Mr. Wiggins. Would you say that any person who is inclined to
take heroin would be better off taking methadone instead of heroin ?

Dr. Jaffe. I am not sure what you have in mind when j-ou say any
person inclined to take heroin.

22l

"''Mr. Wiggins. A lot of people are inclined to take heroin for very
poor reasons, but they do it, nevertheless. Is methadone better than
heroin t

Dr. Jaffe. Well, oral methadone is a lot safer than heroin bought
from a pusher on the street without any question. If I had someone
absolutely committed to finding out how a narcotic drug felt and
you presented me only two alternatives, either they wanted to buy
some heroin on the street, cook it, or take a swallow of oral methadone,
I think the answer would be obvious. They would be a lot better off
and safer taking methadone. But I don't know if that is what you
are driving at. .

Mr. Raxgel. Let me ask this : Would your answer be the same it
the heroin was being taken orally, notwithstanding the difference m
reaction?

Dr. Jaffe. No; if these were known dosages of heroin and metha-
done, both taken orally, I don't think that it really makes much ciiffer-
ence at all.

Mr. RaXgel. Would it make much of a difference if the methadone

were injected?

Dr. Jaffe. Oh, yes. Injectable narcotics produce some very rein-
forcing effects in the sense that you can do research on animals and
you can show that animals, given an opportunity to inject _ intra-
venously any one of the narcotics, learn very quickly to keep injecting
those drugs.

Mr. Waldie. Doctor, may I interrupt you at this moment ?

In response to Mr. Wiggins and Mr. Rangel's question, I under-
stood you to say that if you had the same control over heroin in terms
of quantity and the manner in which it is administered as you have
over methadone, the man taking heroin would be ill no better or worse
position than the man taking methadone ?

Dr. Jaffe. No. The question was in response to a single dose.

Further, j'ou are talking about chronic administration.

Mr. Waldie. Let me phrase the question this way, then : There is a
concern among some people, and I share it, that we are substituting
one addictive drug for another. Is there some advantage to that sub-
stitution, to substitute methadone for heroin, other than the advan-
tages that you have stated, that there might be an infection because of
the intravenous injection and there might be adverse effects because
of the impurity of the heroin ?

Dr. Jaffe. Oh, yes. .
):Mr. Waldie. Are there other results that are beneficial for use of
methadone rather than heroin ?

Dr. Jaffe. In our present context, without a,nj question. There are
two; ■'' ■ '

First of all, the oral absorption of heroin is somewhat erratic. Fur-
thermore, the drug— and I am not sure this has been studied in de-
tail— is probably not even in significant quantity going to have smooth
duration of action if you were to give it once a day under observation.
: 1 mean, if you were still in the position of looki'^o- for something
which lasts 24 hours, of letting peonle take it home for their own use.
As soon as you begin letting people take it home to]H,have trouble
with illicit diversion and accidental ingestion. ■■'

"ff ! y rfCMJoefiii Y< •: ;o ii.Mcj v.-'I'.

222

Furthermore, in our present context we are deeply concerned about
tlie intravenous use of illicit heroin. The use of methadone provides
one very pragmatic possibility of knowing when patients continue to
use illicit heroin. In our program, patients on methadone have their
urine tested. We know a patient is taking heroin in addition to metha-
done. If we weren't giving them methadone — but were giving them
oral heroin — we would have no way of knowing whether they continue
to take intravenous illicit heroin.

Mr. Waldie. Let me ask one question. Are the results on the indi-
vidual of taking methadone less debilitating than the results on the
individual of taking heroin ?

Dr. Jaffe. Let me try to state this as precisely as I can.

Mr. Wiggins. That is a clinical setting, right ?

Mr. Waldie. Eight.

Dr. Jaffe. No one. to my knowledge, has done adequate, careful,
controlled studies of large doses of oral heroin. So we are always
forced to compare the British experience with self -administered in-
travenous heroin with our own experience of regular administration
of oral methadone.

So the two situations are not comparable.

To the best of our knowledge, intravenous heroin is not a good drug
sociologically or psychologically, because the ups and downs of a
short-acting drug get people going from a "high" to a little bit "sick"
and then they want to be high again. It is not a drug permitting easy
stabilization and functioning — the stabilization of the kind that lets
citi7:ens take care of business.

Methadone does permit that when used orally.

Mr. Brasco. May I ask one question ? You sort of confused me as to
what was said, at least as I understood it, by Dr. Gearing yesterday
when we spoke about taking heroin orally.

If I understand correctly. Dr. Gearing said there would be no effect.
Exactly what is the effect of taking heroin orally ?

Dr. Jaffe. Taking heroin orally ?

Mr. Brasco. Yes ; has it the same effect that you get when you use
it intravenously ?

Dr. Jatte. No.
' Mr. Brasco. What effect does it have ?

Dr. Jaffe. Well, the effect you get when you take a drug intraven-
ously, a very short onset of action.

Mr. Brasco. No ; I am talking about taking heroin orally.

Dr. Jaffe. Heroin was given orally. It was used in this country until
about 5 or 10 years ago when we ran out of old stocks for cough
medicine.

Mr. Brasco. I understood her to say — and maybe I am laboring
under a misapprehension — that if you take it orally there was basically
no effect.

Dr. Jaffe. From oral heroin ?

INIr. Brasco. Right ; as opposed to taking the methadone orally, you
would have the stabilizing effect and it would prevent the cra\nng for
the heroin. "When you take the heroin orally, I got the impression that
you were sort of in the same position as not having taken it.

Dr. Jaffe. Well, I think you are asking two different questions. One
is: Is heroin as effective a drug taken orally as by injection? The

223

answer is that its oral to parental ratio is not as high, meaning that
it takes a lot of heroin orally to give you a blood level so that you
get an effect. That is also true of morphine. It is also true of many
of tlie standard narcotics tliat we use in medicine.

If somebody really has pain, you would have to give them a shot
of a drug like morphine. Methadone is one of the few drugs in the
narcotic analgesic group that has a good oral potency, meaning that
you don't have to give a tremendous amount of it by mouth to have
an effect.

Mr. Brasco. As a practical matter, what would one take heroin
orally for?

Dr. Jaffe. The same way you take codeine, you give a little

Mr. Brasco. We are talking about people addicted to drugs.

Dr. Jaffe. Nobody would ever take lieroin orally if they were ad-
dicted. It is too inefficient. People sniff it, some people smoke it, but
probably nobody would swallow it, simply because it is not efficient.
The body metabolizes it before it gets a chance to be active.

Chairman Pepper. Mr. Waldie, have you any questions?

Mr. Waldie. Just one question. Dr. Jaffe. If the Federal Government
were to participate in some way in this whole problem with which
you have been involved, would you discuss, No. 1, the areas in which
you think our participation would be most beneficial ; and No. 2, would
you believe in terms of priorities of expenditure, which would be the
nature of our participation, that there is one portion of this program
that is more deserving of expenditure than other portions? Could
you comment on those two areas ?
, . Dr. Jaffe. WTiich program are you referring to ?

Mr. Waldie. I don't know. I want you to tell me. I want to to tell
me what the Federal Government, in your view, should interest them-
selves in most in terms of priority or expenditures.

Dr. Jaffe. Well, in the entire area you could divide it into things
like direct support of treatment, development of research directed
toward the development of treatment and control systems, direct con-
trol of drug availability and training ; training both for research and
treatment.

Now, obviously there are some areas that you could say need priority.
Our experience has been that patients who are chronic heroin users
who want treatment with methadone should be given that treatment,
because it is better for them and everybody in the community, and
therefore that should be a high priority for the Federal Government
to see that the funds are there to provide sensible, rational treatment.

Now, if there are other treatment areas that can be demonstrated to
be effective for those people for whom we will say methadone is not
effective, such as young polydrug users who have not been on drugs
very long, people who just don't want to be on methadone, people
who want to come off methadone. In our experience many, many peo-
ple feel they have had their lives stabilized, they would like to come
off. Such treatments should be provided or developed if they do not
now exist. That should be done and the Federal Government should
see that they provide that.

There are some problems in communities. I cannot speak officially
for any State or community, but I do know there are certain obliga-
tory expenditures they cannot get out of. I read in the paper that wlien

224

the Federal Government decides it -svill not support welfare or some-
tliin^ else, the State must do that, and therefore it can only trim op-
tional kinds of things, mental health, treatment of addiction, and
education.

So that the Federal Government has to realize that as it shifts its
priorities, the States are in a reciprocal relationship. Communities
also set priorities and traditionally these treatment programs have
been viewed as optional; that is, it is optional rather than legally
required that there will be narcotic treatment programs.

Mr. Waldie. One final question. Doctor.

Do we have enough experience yet to knoAv whether it is more
difficult, at first, to an indi^ndual in setting off of methadone addiction
thn n heroin addiction, for example ?

Dr. Jaffe. The withdrawal syndrome from heroin, given the doses
that most people use in the street, is pretty much a thing that is over in
a matter of a few days. The difference is that the relapse rate is phe-
nomenally high. Certainly people who withdraw from methadone are
complaininir mildly, but somewhat longer. It is dragged out. ovqi: a
period of weeks or so. ?fj', .;:i(f,v. // .'ija

Howei^er. our experience has been when you stabilize someone on
methadone and he has gotten to the point where he has a job and is
back with his family, and thei-e are a number of social supports, and
he has been accepted by the community as a responsible citizen he
may have a tougher time when he withdraws from methadone in the
sense that it is sort of a dragged-out situation, but the probabilties
of being; able to remain stable may be slightly higher.

I don't think enough work has been done as yet with trying to take
people off methadone to try to answer that question in any definitive
wav; It is one of the research areas tliat will deserve attention.

Mr. Waldie. Thank you.
'Chairman Pepper. Mr. Wiggins.

Mr. WiGGT^rs. Doctor, I want to commence vHth a hypothetical
question. Let us suppose, hypothetically, that methadone were totally
substitued in our drug culture foi' heroin, but that it was used in exactly
the same way, the shooting of it, using dirty needles, cutting of it.
using impurities ond other things, let's suppose it happened that there
was a total substitution in, that war for heroin: would we be better
off or worse off? ^f^^^V- '''' ''^'''"■'' '" '' '■' '/^"'- ''■''^[^ '[■■■'"'.

^ Dr. JAffe. '"N'o; the advantages of methadone are not nearly as
pharmacologibally — —

Mr. Wiggins. Just respond to that question, better off or worse off?

Dr. Jaf*t.. We %oiild be no better off. T don't think we would be any
worse off. It is hard to picture a situatioh niuch woi'se off.

The advantage of the present situation is as mnch in the system by
which the methadone is controlled — its supervision — as in its "pharma-
cological differences. ^ ^^ .oifohKO loi.t !.■ oi,i v- -; ^."

INIr. Wiggins. I tliink it is an important question, because conceiv-
ably we could end up in that position. T would think there is a ])ossi-
bility we might be better oft'. At least the narcotic would be produced
by local manufacturers who would be subject to somewhat more con-
trol than Turkish farmers. Perhaps the Mafia or some other organized
criminal activity would not be so intimately involved in its distribu-
tion. These may not be insignificant advantages.

99;

Dr. Jaffe. I would say that I can't conceive of a situation, in know-
ing what we laiow, where we would permit the situation to deterior-
ate to the point that methadone would be that readily available for

intravenous use. M'^-rr^ n >■•■■.

Mr. WiGGixs. Many of us have harbored the suspicions, at least,
that metliadone programs proceeded from the assumption that the
only way to take crime out of a drug business is to make the drug
available to addicts at a reasonable cost and to maintain their habits.
For many reasons, however, some of which Avere political, we just
couldn't bear to provide them heroin as did the British, so we came up
with a substitute called methadone; is there any truth in that

suspicion? .4^ Y^nr\y . f/ri')

Dr. Jaffe. I thnik that is an oversimplification that misses many
of the critical distinctions between methadone and heroin.

First of all, the pharmacology of this drug is such, as I pointed out
before, that you can get somebody psychologically stabilized and the
contrast between a fairly stabilized individual taking an oral medicine
which has very few peaks or valleys, and somebody taking a drug,
short-acting or intravenous, going up and down several times a day,
is dramatic. People on this smooth-acting drug can function iai terms
of devoting their energies to productive activity. ; . . >

People going up and down, taking intravenous doses, really do not
function Avell. ■<{ -t\':->

J Second, we can supervise a long-acting eilective oral drug, meaning
that if we want tQ, and if we feel it absolutely necessary, we can pre-
vent methadone from being on the street. Very often, frankly, at much
too ^reat a cost to the rehabilitated patient.

Mr. Wiggins. I would like to know your views on how we can pre-
vent methadone from being easily available on the stree^; subject to
being shotup, cut, sold at a profit just like heroin. ^

Dr. Jaffe. Well, No. 1, the dosage form of methadone could be so
uniform you can dissolve it in fruit juice and it is very hard to extract
,and to in any way dilute it and shoot it.

Mr. Wiggins. Say that again. Is it difficult to shoot it ? 5

Dr. Jaffe. H you dissolve methadone in 4 ounces of orange juice
and then try to concentrate it so that you can get it into a syringe, you
get a gummy, sticky mass. There is nothing you can do with it. That is
the original way it was developed, and many of the original programs
went to great pains to see that this was done.

Second — and I must say that as the volume of patient j.oad increases
it is becoming difficult to do this, and it may be a matter of funding
and other things — initially every new patient came to a clinic once a
day. He drank the methadone under supervision. The only medicine
on the street was in his belly. There was no medicine to sell or illicitly
distribute. Theoretically, only the most stabilized patients are given
the privilege of taking methadone home with them.

Mr. Wiggins. But the fact is that methadone is on the street.

Dr. Jaffe. I can't conceive of a situation where you get uniform
adherence to a set of regulations, no matter how sensible they may be.
You always have practitioners who won't adhere even to a very sensi-
ble, rational set of regulations; and you always have a very, small
minority of patients who are mavericks^ who don't have a sense of
responsibility.

I have presented one generic kind of solution to this problem. The
generic solution is a longer acting substance. If you had a methadone
that only had to be given three times a week, people for a while will
come three times a week, and there is no drug on the street — none,
zero.

Now, we have one such drug

Mr. Wiggins. Excuse me.

I take it that a private physician could nevertheless order from a
pharmaceutical house a case of methadone and dispense it subject only
to his personal medical judgment on the need for it; is that risrht?

Dr. Jaffe. No ; I would say there is some vagueness under the Fed-
eral regulations. Most States are able to delineate the difference be-
tween treating a temporary syndrome — such as somebody waiting to
go into treatment, or treating someone with a chronic painful illness —
and maintaining a narcotics user on methadone with greater precision.
Therefore, a physician would be in violation of State laws in most
States.

Mr. Wiggins. What controls operate on a private physician other
than his own judgment in dispensing of methadone ?

Dr. Jaffe. Well, in our State we have defined the chronic treatment
of addiction with narcotic drugs as not yet an established routine medi-
cal procedure. So that in a sense it is acceptable as medical treatment
only in programs approved by the department of mental health. If
that physician does not seek such approval and adhere to a protocol,
he may be subject to prosecution under our uniform drug law.

Now, it may be that he could fight that successfully. We don't know.
But — -

Mr. Wiggins. First of all, is this a matter of State regulation?
Dr. Jaffe. Yes.

IVIr. Wiggins. And, therefore, there may be 50 different sets of regu-
lations in the country ?

Dr. Jaffe. That might be the case. That is for 50 or so.
ISIr. Wiggins. Is there any legal prohibition against a doctor who is
so inclined from purchasing great quantities of methadone?
Dr. Jaffe. Not to the best of my knowledge.

Mr. Wiggins. If that doctor were so inclined, what legal prohibitions
preventing him from dispensing it at his front door or back door ?

Dr. Jaffe. I suppose the only prohibition would be his concern that
a promising medical career at which he earns a reasonable living could
be permanently terminated by successful prosecution under a felony
charge of illicitly selling narcotics.

Mr. AViggins. Is it a defense, so far as you know, to that charge that
the doctor believes in the exercise of his professional judgment that
the person before him was an addict and who would profit from the use
of methadone ?

Dr. Jaffe. It would be a defense, I suppose, onlj'^ if a substantial
number of his professional colleagues in that community stood up
and said this is the good i)ractice of the community and it is in the best
interests of tlie patient aiid comnumity. Tlie cluinces might be he
would be convicted of a felony.

Mr. Wiggins. Given the situation as you described it, are you satis-
fied that is an adequate control ?

227

Dr. Jaffe. I think that more work has to be done in delineating- the
conditions under which these drugs can be used for the treatment of

addiction. ,. . p xxtt^ • -•

I am not satisfied with our current apphcation ot a l^D, nivesti-

gational drug. . ,

On the other hand, I have no pat solution for the best way in wnich
our health care delivery system can become involved in delivering
the services to the advantage of the patient and the community.

I mean, we have to protect both, and we have to serve both. I think
more work has to be done on it. I am not satisfied with our present
controls, nor would I want to see us return to a purely repressionary
police state during which no physician would ever let an addict inta
his office for fear he might be some kind of local police informant,
and that if he treated him in any way he might be prosecuted.

That was an era of sheer terror for physicians, and the mere fact
somebody might be an addict was sufficient reason for them to pick up
the phone and call the police and say get this whatever-it-is out of my
office.

Mr. WiGGixs. As I recall it, when they operated under a system
of private dispensing of heroin the abuses were so widespread that the
only way to control it was to confuie it to a clinical setting.

Dr. Jaffe. Well, I have no personal knowledge of what went on. I
read the reports. I know the details. I am not sure that you w^U get
a consensus on what really went on.

It is obvious that there is no way of dispensing or prescribing short-
acting drugs without lisking significant illicit diversion. We have said
the best clinics under the best controls, trying to dispense heroin,
would open themselves up to illicit diversion, that you need a long-
acting drug that you can supervise and preferably one that can only
be used orally. We have such pharmacological substances available. It
has to be realized that methadone wasn't even known to be an effec-
tive narcotic drug until the late 1940's, in this country.

I mean, some of the pharmacological knowledge that we are talking
about never existed in the 1920's when they tried these clinics. So tliat
one couldn't even experiment with the possibility of a carefully regu-
lated controlled system of treating those people who are willing to be
treated in this way. I think that we are now in a different technologi-
cal ball park. We have to stop harking back to old days, when we used
old technology and look at what we can do now, what our potentials
are and what is the best way to strike the best balance in treatment
and still, at the same time, protect the community from widespread
illicit diversion of the drugs we are using for treatment.

Chairman Pepper. Mr. Brasco, do you have any questions ?

Mr. Brasco. Yes; I wanted to ask Dr. Jaffe: In connection with
the methadone program, would there be any great difficulty, given the
fact that there is agreement over the danger of abusing the use of
methadone in the street, why is it not possible, at least from the point
of view of stopping those who are in treatment from proliferating
use in the street, having users report once a day to take the methadone
at the clinic so we know we can stop that kind of abuse ?

Dr. Jaffe. I think it is a fine question. It has been raised a number
of times.

228

The answer tends to be a very practical one, which is that for the
first 3 or 4 months you do insist that somebody come every day.
But if you are successful, if he begins to view himself as a produc-
tive citizen, if he now has a job and he has to get to that job on time
and come back, and your clinic doesn't happen to be either near his
horne or near his job, you are asking him to somehow get to your
clinic once each day. It may be very difficult for you to keep the clinic
open long enough for him to get there every day. It may be, for ex-
ample, impossible to get nurses to work in certain communities after
sundown.

Mr. Brasco. It becomes a problem of logistics ?

Dr. Jaffe. Primarily a problem of logistics. It also becomes a prob-
lem of self-image. We have had people in treatment for 3 years, work-
ing every day, earning retirement benefits. They haven't used any
drugs and they are still wondering why everybody else is trusted with
phenobarbital for epilepsy, and other people are trusted with all kinds
of drugs. ■,.,.,,,

Mr. Brasco. Then j^ou are saying it has a definite effect in the re-
habilitation program if the program doesn't give that basic show of
trust?

Dr. Jaffe. I think for many people that is the case. But I am nqt
willing to push the logistics aside, because logistics happen to be para-
mouiit in a place lilje-I^os Angeles, which has virtually no public
transportation system. You are, in effect, saying, "We want you to get
rehabilitated, but so rehabilitated you can have a .(?ar to get to the
, clinic every day."

Chicago has its own transportation problems, as every urban area
does. They just can't afl^ord to come to the clinic every day.

Mr. Brasco. Doctor, one other thing now. ajio tjoy 1riIi s/nb snil- n

In connection with that, then, and I don't knowTf you have .aaiy
statistical information on it, but wliat is your experience for the po-
ten<:iality of abuse of allowing the methadone to get out on the street
illicitly, coming through those in treatment ?
; ,. , Dr. Jaffe. It is minimal, butifc.is'riot zero.

Mr. Brasco. Right. : (^ :• < ,■ ,

Dr. Jaffe. I want to emphasize that anybody who is riealistic knows
that we are not treating a group of Boy Scouts.

Mr. Brasco. So what you are saying is it is a tolerable risk ?

Dr. Jaffe. Let's ask what we are trading that risk in for. Tliet's'say
5 percent of people leak their methadone. Primarily 85 to 90 percent
of that leaked methadone is going into the people who are currently
using heroin. l

So, frnidamentally, the methadone will remain in competition with
the illicit heroin market for the time being, and that really doesn't
represent a major social catastrophe at this points' yiv^.r ■?.':( »,7

Mr. Brasco. You said something before that was interesting to me.
You said that when they dispense or when you dispense methadone
you use it in — or mixed with — orange juice. r -^iii ^

Dr. Jaffe. Fruit juice. ''rnui m '■y<\>

Mr. Brasco. And that it is most difficult to conctotrate,-tilaiat yoit get
a gummy substance ? > ■•■<,j. ■■>'

Dr. Jaffe. That is true. ■ ^ o

229

Mr. Brasco. Then for those who are shooting, what are they doing,
using the mixture of the juice with that or some other form of metha-
done which is dispensed, such as pills ?

;Dr. Jaffe. That is a fundamental point. Not everybody is as con-
cerned about this issue as we are, and therefore some people are using
different forms of methadone tablets, methadone diskets, which may,
in fact, at least in their presently constituted form, be so constructed
that it is possible to create an injectable form from jt. We knoM' that
when once dissolved in fruit juice of various kinds, it becomes impos-
sible to extract methadone with ordinary techniques.

Mr. Brasco. So then as a starter, if we got to the point where metha-
done was only dispensed with fruit juice, as you were talking about,
and I assume both are equally effective, then we would be taking a long
step in the right direction in terras of having abuse of it reduced?

Dr. Jaffe. May I make one comment? Let us avoid rigidity. It is
always the exception that makes life difficult. We have a patient who,
after Avorking for 2 years, wanted to visit his wife's family in
Europe. I would trust him with my life. I know him very well and his.
family and his wife. '^' ' ' '

If we gave him 21 bottles of juice — he is going for 3 weeks — No. 1,
it would spoil ; and No. 2, what do you think customs would say about
these 21 bottles of juice ? You tether him to a clinic. There has to be
some form used for the exceptional case, and 21 little tablets that would
handle the situation, make it possible for him to function as a human
being in the exceptional situation.

Mr. Brasco. Assuming that all of them are not going to Europe, and
I take thatto be a fact oini nni m

Dr. Jaffe. That is true for the overwhelmiilg majority.

Mr. Brasco (continuing). So that we still would be taking a long
step in the right direction wdth this little aside that you have in terms
of possible exceptions cropping up ? ^^''t^ -f '* ' ^■■' ' '

Dr. Jaffe. Eight. I am not unaware this is a legislative group. So I
am saying I want to avoid seeing thmgs couched in such language
that an exception automatically becomes a crime, because as soon as
you do that you really reduce the possibility of effective treatment.

Mr. Brasco. No ; I wasn't talking about that. I was trying to define
an area where we might recommend something.

Dr. Jaffe. With strong recommendation for the exceptional cases
it would be very helpful and would certainly reduce some of the
present problems.

Mr. Brasco. Just one last question.

"VVTien you use methadone intravenously, do you have the same expe-
rience in terms of it becoming a short-lasting kind of effect as with
heroin ?

By that I mean if you start to shoot it, would you have to use it
several times a day ?

Dr. Jaffe. To the best of our knowledge. It is a little longer acting,
but you certainly would have to use it several times a day. In practice,
people who use methadone could use it several times a day.

Mr. Brasco. Thank you. I have nothing else.

Chairman Pepper. Mr. Steiger.

Mr. Steiger. Thank you, Mr. Chairman.

230

I realize we are running late.

Doctor, I assume you have personally interviewed a good many of
these l.noo patients.

Dr. Jaffjl In the beginning I had enough time to see a lot of them
personally. I must say as the program grows I become progressively
more insulated from the direct patient care.

Mr. Steiger. Do you have any experience with a methadone addict
^ho reported into the program

Dr. J.\FFE. Using methadone?

Mr. Steiger. Yes. sir ; a man addicted to methadone?

Dr. Jaffe. Yes, certainly.

Mr. Steiger. "Were you able to ascertain how he became involved
with methadone or how he acquired it ?

Dr. Jaffe. Well, some of them buy it illicitly on the street. Where
they get it is not clear, but obviously some people have, as they have
for many years, come to doctors with stories of chronic pain, with
things that would justify the prescription of oral methadone'.

Furthermore, once in a while, before we had a program, there were
physicians who, I think in all good conscience, knew somebody who
was working and functioning and the alternatives were lieroin or
methadone. The physician would say, "I understand you are trying
to get into a program,'' and for a few months he would prescribe this
medication. He would call us up and say that this man was on metha-
done for several months, and say, "I have been prescribing for him,
this is the dose, and the sooner you take him into the program' the
better off we will all feel."

Mr. Steiger. Did you run into any heroin addicts who had beeir
acquiring a regular source of methadone from a licensed physician,
and because of either the death of a physician or his stopping, re-
ported into the program ?

Dr. Jaffe. Oh, that is not uncommon.

Mr. Steiger. I am not as concerned as my colleagues are that the
responsible clinics are going to leak a sufficient volume of methadone
to create a new hazard. I am very concerned that there are physicians,
regardless of their motives, who are continuing to prescribe methadone
and/or heroin. I wonder from your experience, again on the basis
of interviews, if you feel there would be any merit in legislatively
limiting the dispensing of methadone and heroin to licensed clinics
and thereby making an absolute prohibition against the private physi-
cian dispensing it ?

Dr. Jaffe. Well, first of all, there isn't any hei'oin ever dispensed
or prescribed. There is none in this country. It has been outlawed.
There was a little bit of stock in Philadelphia for a few years after it
was outlawed, but there is none at the present time.

I am generally opposed to any absolute legal prescription of some-
thing, because then you I'un into a situation where you ha^•e done
what you set out to do, you have rehabilitated former heroin users and
they are offered a job in some community where there is no clinic.
He can't accept that job, and he can't in effect, change his life style
and start all over again.. Under appropriate conditions, if there were
no absolute medical prescriptions, he might be able to make a private

231

arrangement with tlie physician who would handle this problem on an
individual basis in a carefully regulated way.^

Without that possibility this man is limited to any area that has
a clinic and largely these clinics arc limited to the large urban areas
that can sustain a clinic of a hundred or so people.

Mr. Stetger. But isn't it conceivable that we could extent the au-
thority to permit the clinic to approve the physician for that specific
patient '?

Dr. Jaffe. That becomes another issue. In other words, what you are
saying is that no physican unaffiliated with an approved program
would be permitted to prescribe methadone for addicts.

Mr. Steiger. Based on your experience, in terms of volume of il-
licit methadone, isn't there a far greater propensity for the private
physican to be the source of the illicit methadone than there is for
the clinic, the approved clinic ?

Dr. Jaffe. Well, I think in terms of the ratio of patients treated and
the amount they let leak on the street. I would say that may be true.
Obviously, in terms of absolute numbers, a program treating 1,600
people will be responsible for more leakage than any one physician
treating a few patients.

In other words, if he is only treating five or six people,
a single physician probably will not have as much leakage as a
j)rogram treating 2,000.

Mr. Steiger. If those five or six people are dealers, themselves ?

Dr. Jaffe. Well, the physician would have to be rather naive.

Mr. Steiger. How about dishonest? How about the dishonest
physician?

Dr. Jaffe. Dishonest physicians should be treated like any other
dishonest individual?

Mr. Steiger. But right now he is not violating anything?

Dr. Jaffe. As I said before, I think we have to think through our
regulatory procedures so that the dishonest physician is treated for
what he is. He is a pusher, operating under cover of his medical
license.

Mr. Steiger. Eight now, except for whatever State regulation may
exist, he would not be in violation, as Mr. Wiggins pointed out, he
could appeal to his medical judgment and say this, in my best judg-
ment, was what this particular patient needed, even if it obviously
wasn't ?

Dr. Jaffe. Well, I certainly think we have to think through how we
will control the dishonest physician, there is no (question about that.

Mr. Steiger. Would you agree there is a question of the dishonest
physician who could be a source of methadone ?

Dr. Jaffe. How could one deny it ?

Chairman Pepper. Mr. Mann.

Mr. Mann. No questions.

Chairman Pepper. Mr. Winn.

Mr. Winn. Two quick questions, Mr. Chairman.

Doctor, I missed the first part of your testimony. Are any of your
cases ambulatory when they come to you ?

Dr. Jaffe. All of our cases are ambulatory when they come to us.

232

' ']Vir. Winn. Tiien you mentioned, I gatiiered, tlios'e that are now on
methadone?

Dr. Jaffe. People who are in a residential setting can be on metha-
done or withdraw from methadone in the same facility. We have no
difficulty with that.

Mr. WINN. I missed the point. I thought you said these were not
people under hospital care.

Dr. Jaffe. No ; because it is not a hospital. It is a residential setting,
staffed, but we don't have round-thc-cloclt nurses or elaborate medical
equipment. This is one way of reducing the cost. We don't have, in a
residential setting of relatively healthy people, a little buzzer you press
and have three people running with an emergency cart.

Mr. Winn. After 3 days they can go home ?

Dr. Jaffe. In an emergency setting ?

Mr. Winn. Yes.

Dr. Jaffe. No ; they might live there about 3 or 4 or 5 weeks, trying
to straighten their lives out.

Mr. Winn. They come fropi all over the country, outside the com-
munity you serve ?' '"'''^ ®«^' ■^'"' ' .... 'T''^

Dr. Jaffe. Yes. We only have four or five residential facilities in
the State.

Mr. Winn. All right. Are these black or white, or both ?

Dr. Jaffe. We have all integrated facilities.

Mr. Winn. Thank youJ ''■ ■^' '

Chairman Pepper. Mr. Murphy.

Mr. Murphy. Doctor, I just returned from an around-the-world trip
with Congressman Steele from Connecticut, and the purpose of the
trip was to impress upon these countries that are engaged in opium
growing to curtail their production, and in fact eliminate it.

One distressing point we came across in Southeast Asia is that the
type of heroin that our troops are becoming addicted to is of a puritj^
of 94-97 percent. In fact, they don't even have to mainline it, they are
snorting it and thev are smoking it.

My question to you. Doctor, is : If this is compared to a 6 or 7 per-
cent purity injection of the United States, what is the outlook or the
prognosis for those fellows when they come back to the States. Would
you just have to increase your intensity using the methadone treatment ?

Dr. Jaffe. No; eventually you can stabilize people on moderate
doses. The doses of methadone that are normally used for the heroin
users that we now have, Avill be adequate to handle people who start
off using even pure quantities of heroin. Their habits aren't that great
and they can be brought down to a stabilization level with very little
difficulty.

I don't anticipate the need for modifying dosages in any way, if one
decides that is the best way to treat a young Vietnam veteran who has
never had any other treatment. I don't mean to imply that would be
the routine or immediate response to finding out that a veteran has
used heroin in Vietnam. It may be that you use this approach only
when other things have failed. This is still to be determined.

Mr. Murphy. Tliank you.

Cliairman Pepper. Mr. Sandman.

233

Mr. SANDMAxlTf ari'AcTcIi'ct had the choice'b'efween herein aii'dmetha-
'done — I gather there isn't any choice — he would choose heroin ?

Dr. Jaffe. Intra venbus heroin versus oral methadone ? I think most
addicts TTOuld do so : yelsi''^'" v,oii -.

Mr. Saxdmax. From whfft you say, methadone is used on some one
ah-eady addicted to heroin? '

Dr. Jaffe. That is how we lise it ;' yes.

Mr. Saxdiiax. Have you had any experience where you have liad
some people come in who are addicted only to methadone?

Dr. Jaffe. People' wlio ha,ve neyer used any other drug ? Yes ; a few
such cases. ia.3.^3 li^noij^y

Mr. Sa^'dmax. But they are rare ? ^^ •'; ^-^;- \/''', ,

. Dr. JxVFFE. In this country. They are not so rare in' EnglkiYd' where
people are beginning to prescribe, methadone tliat can be used
mtravenously. fe^v, ^h.oc. odi .n i

Mr. Wixx. Is it accurate for me to assume from your testimony that
in the absence of some other way or some other drug you feel metha-
done is serving its purpose in allowing the heroin addict to at least be
able to ciirry but his responsibilities of life: is tlikt j'bur position?
, I)r.„jAFFE. That .is (Sur primary position. It allows many of them
to function, but' we are hot prefeentilig' it as a panacea. Once you get
everybody who can be effectively treatfed with methadone, treated and
functioning, you will still need other programs for' those people who
have not "made it" with metha;dbne oi- whb are still not interested in
methadone. , , rf . j • . , '"".',]

. Mr. Wixx'tou 'm hot' Hlaimlhg'W is^^^ehd^ :^6s^t,:I understand,
^ut'in the absence bf somethiiig better you feel it'isf- '^" :""''*" ^I'' ^'^■'
"' Dr. Jaffe. I have made the pohit and I thiiik it 'should be available
to all those people who woi;ld like to.give it a try and who qualify
for it.' ' ' ''■ '' ■' ' ' "'■ ■ ■■ ■/' ■; ,,' "

'' Chairman Pepper, Mr. Rangel. ■Pif/Oi'-

f . Mr. Raxgel. Yes. ^ .,l,fr. ■ r. a ^ \

Doctor, about the 1,G0() hafcotics users, you[py "ifneT ai^e- integrated,
or were vou talking about staff' ? , ■ ■ •;

;., Dr. Jaffe. Staff , too.

^ Mr. Raxgel. Well, with the users, what would you consider the
ethnic breakdown of your State's program, in the patients?

Dr. Jaffe. Well, I haven't looked at it for several weeks. It was, for
the first couple of years, about 72 percent black. A small percentage are
Puerto Ricans, Mexican Americans, and the rest white.

Mr. Raxgel. Considering this ethnic breakdown and considering
the population of your State, this sampling reveals an overwhelmingly
high minority breakdown. Using minority as it is generally used,
this is an extremely high minority figure ; is it not ?

Dr. Jaffe, I think that might be misleading. Our program, as I said,
be^gan as a pilot program. We were going to diagnose the community.
We were not going to start treating the entire community or State,
The question was: AVhere shall we put our initial facilities"? The deci-
sion was made to locate this around the University of Chicago, where
the University of Chicago could lend its iDrainpower to the
development.

60-296 — 71 — pt. 1 16

234

So having put it in the area, having made our facilities immediately
available in a geographic area where 85 percent of the population is
black, it is not surprising that we had an overrepresentation for the
program as a whole. They had the most immediate access. They were
given first priority because they were there.

It wasn't until a year and a half later that we had the first treatment
facility on the northside of Chicago where Caucasians, Puerto Kicans,
and Mexican Americans could find it equally accessible.

Mr. Raxgel. But if you were to project not only your State's but the
Nation's methadone treatment programs, would not that same ethnic
breakdown be bound to exist on a national basis ?

Dr. Jaffe. It would be very hard for me to really project it nation-
ally. I would guess that in most of the large urban areas of the East
and perhaps the Midwest there would be an overrepresentation of
black patients. However, in the Southwest it would be Mexican
Americans.

Mr. Ranoel. But they would be people in the lower economic level
of American life ; wouldn't they ?

Dr. Jaffe. I think until very recently heroin addiction was primar-
ily a problem of the lower socioeconomic groups.

Mr. Rangel. Now, with all of your priorities in terms of where Fed-
eral money should be spent, I think you listed research and training.
Do you not think that perhaps the causes and the reasons why a partic-
ular economic group is prone to become addicted to drugs should not
be one of the priorities ?

Dr. Jaffe. That was assumed under research. I talked about research
into epidemiology, into what is responsible for the epidemics, what is
the natural history of these things, and how to respond to these to
epidemics.

Under the research I listed those questions and I recall saying the
first priority should be to make treatment available to everybody who
wants it.

Next we are to find out about why this happens m the neighborhood
it happens in and what the trends are.

Mr. Rangel. I am wondering. Doctor, if a different economic group,
that is, a more affluent economic group, were afflicted by a similar tyj^e
disease, whether or not we would be talking about ma king methadone
so available as a possible cure to disease or whether or not there would
be a concentration on research rather than just expansi< n.

Dr. Jaffe. Well, I can only tell you that everyone I h ave talked with,
given the option of waiting for more research with the possibility that
in the meantime their children or relatives might die of overdoses or
go to jail, opts for "Let's take what we think is most eff< ctive and make
it available."

Mr. Rangel. I don't see where you have too many choices, because
you have the problem that you have to deal with and the best thing
American research has come up with has been methador e ; that is vour
professional opinion ?

Dr. Jaffe. Well, for large-scale operation ; yes.

Mr. Rangel. But in terms of national research, are you satisfied that
this Nation is doing all it can to research a solution to the drug prob-
lem that we are having at the present time ?

235

Dr. Jaffe. Well, we have pointed out areas where more could be
done. I think that lookintr at it from the point of view of somebody
who has reviewed research grants and applications and looked at the
funding, all the good brainpower that wants to get into the field, you
know, is able to get involved.

The issue is getting more brainpower to bear on the subject.

Mr. Rangel. My last question is: Are you satisiied that the fact
that the victim of this epidemic happens to be in the low economic
strata of our society has not affected the determination of our Ameri-
ca's research in doing as much as it can ? You don't believe it would be
any different if we were dealing with a more affluent group ?

Dr. Jaffe. Well, I suppose that it is already dealing with a more
affluent group. There are a number of very wealthy suburbanites who
are extremely concerned. But I think if you escalate it into a crash
program, a tremendous amount of money into research per se, hoping
that the competent researcher will materialize, you may be disap-
pointed. You need to gear up for these things and support people. I
think all you would do with crash programs is bring in a lot of mar-
ginal people.

If you nave a phased planning and say, "Yes, we are concerned and
at this stage we will have to bring more people into it." Then, in fact,
you have a program that will bring more people into it.

I don't think that research in this area is being underfunded, to
answer your question more directly, because the problem of heroin
addiction affects primarily lower socioeconomic groups.

Mr. Ranget.. Thank you.

Chairman Pepper. We are running considerably behind here.

Do you have any questions? Mr. Brasco?

Mr. Brasco. I just wanted to ask Dr. Jaffe — and if he answered it
before I will get the information from someone else.

We were sort of interrupted when we were talking about the possi-
bility of developing a longer lasting drug, other than methadone, and
you said you didn't want to promise anything, and at that point you
went to something else.

Did you get to that, because I was a few minutes late and I am
wondering what the prognosis is for developing it.

Dr. Jaffe. I think the prognosis is excellent. I think it is only a
matter of time before we will be able to discuss which specific drugs
might be able to be used, and which would have significant advantage.

Mr. Brasco. Are you saying we have them now ?

Dr. Jaffe. Yes; we are working on them. We named one that is
under study, that has been under study for a year. There are still some
questions to be resolved that ; yes, this is a drug that can be used on a
Avide scale.

Mr. Brasco. And longer lasting?

Dr. Jaffe. Longer lasting than methadone.

Mr. BPtASCo. "Wliat is the dosage ?

Dr. Jaffe. Three times a week instead of seven times a week.

Chairman Pepper. Dr. Jaffe, you see from the questioning by this
committee how enormously interested we are in your vast knowledge in
this field.; We are very grateful for you coming today and giving us
your testimony. I am sure our committee would like to have the

236

privilege of continuing to keep in contact with you when we come
to the formulation of our recommendations as to what more the Fed-
eral Government can do to combat heroin addiction.
(The curriculum vitae of Dr. JafFe follows:)

[Exhibit No. 12]

CuRRicruLUiii; Vitae of De. Jerome Herbert Jaffe, Dieector, Illinois Drug

Abuse Program i

Formal education : Temple University; A.B., psychology, 1954 ; M.A., experi-
mental psychology, 1956 ; Temple University School of Medicine ; M.D., 1958.

Awards and honors : Temple University, College of Liberal Arts ; magna cum
laiide ; distinction in psychology ; alumni prize : highest academic average ; Psi
Chi Award (scholarship and achievement in psychology); Psi Chi, Honorary
Society.

Temple University School of Medicine : Summer Research Fellowship in Phar-
macology, 19i57; Babcock Honorary Surgical Society: Alpha Omega Alpha:
Merck Award : outstanding achievement in medicine during senior year ; Mosby
Scholarship Award : highest 4-year average in medicine.

Fellowships: USPHS Post Doctoral Fellowship in Pharmacology, 1961-1964.
USPHS Research Career Development Award, 1964 to 1966, 1967-70. ' '

^lajor interests : Psychopharmacology — use and abuse of psychoactive drugs —
biological and sociological aspects.

Experience and training : Rotating internship — ^U.S. Public Health Service
Hospital, Staten Island, N.Y., 1958-59. Residency in psychiatry— U.S. Public
Health Service Hospital, Lexington, Ky., 1959-60. Psychiatric staff— U.S. Pub-
lie Health Service Hospital, Lexington, Ky., 1960-61. Post doctoral fellow, inter-
disciplinary program — Albert Einstein College of Medicine, 1961-62. Post doc-
toral fellow and resident in psychiatry: Albert Einstein College of Medicine
and Bronx Municipal Hospital Center, 1962-64. Assistant professor, Departpient
of Pharmacology and Instructor, Department of Psychiatry, Albert Einstein
College of Medicine, 1964-66. Assistant professor. Department of Psychiatry,
University of Chicago, 1966-69.

.: Present positions : associate professor, Department of Psychiatry, University
of Chicago, 1969 to present. Director, drug abuse program, Department of
Mental Health, State of Illinois, 1967 to present.

, Memberships in organizations: Alpha Omega Alpha, Sigma XI, American
Medical Association. American Psychiatric Association, American Society of
Pharmacology and Experimental Therapeutics, American College of Neuro-
Psychopharmacology, New York Academy of Science, American Association for
the Advancement of Science, Illinois Medical Society, Chicago Medical Associa-
tion, Illinois Psychiatric Society, and World Psychiatric Association.

CONSULTANTSHIPS. ADVISORY PANELS AND EDITORSHIPS

Member, Editorial Board, International Journal of the Addictions, 196&-.

Member. Review Committee, Center for Studies of Narcotics and Dangerous
Drugs, NIMH, 1966-.

Visiting Assistant Professor of Pharmacology and Psychiatry, Albert Einstein
College of Medicine, 1966-.

Visiting Lecturer, University of Texas, Medical Branch, 1966-,

Consultant, Illinois Narcotic Advisory Council, 1966-68.

Consultant, New York State Narcotic Addiction Control Commission. 1967-.

Member, Committee on Narcotics and Dangerous Drugs, Illinois State Medical
Society, 1968-.

Member, Technical Advisory Board, National Coordinating Council on Drug
Abuse Education and Information, 1969-.

Secretary, Section on Drug Dependence, World Psychiatric Association, 1969-.

Member, Advisory Board, Psychopharmacologia.

Member, Committee of the Division of Clinical Pharmacology, American Soci-
ety for Pharmacology and Experimental Therapeutics, 1970-.

Member, Advisory Committee. Drug Abuse Training Center, California State
College, Hayward, California, 1970.

Consultant, Bureau of Drugs Advisory Panel Systems, Department of Health,
Education and Welfare, 1970-.

237

Special Consultant (Technical Adviser), Expert Committee on Drug Depend-
ence. World Health Organization, Geneva, Switzerland, 1970-

Member, American Psychiatric Association Task Force on Alcoholism, 1970-.

Consultant, Joint Information Service, American Psychiatric Association and
the National Association for Mental Health (Project on Current Methods for the
Treatment of Addiction), 1970-.

In addition to these on going advisory and consulting activities, Dr. Jaffe
has been, over the past three years, an invited participant in more than fifty
national and international conferences and symposia. He has also served as
special consultant to a number of State and Local Governments interested in
developing drug abuse treatment or educational programs and has been the
keynote speaker at three Governor's Conferences. Dr. Jaffe has also served as a
consultant to a number of temporary State and Federal advisory panels, as well
as school systems, not-for-profit corporations, and private industry.

PUBLICATIONS OF JEROME HERBERT JAFFE, M.D.

The electrical activity of neuronally isolated cortex during barbiturate with-
drawal. The Pharmacologist, 5:250, 1963 (Abs.) (with S. K. Sharpless).

The rapid development of physical dependence on barbiturates and its relation
to denervation supersensitivity. The Pharmacologist 5:249, 1963 (Abs.) (with
-S. K. Shariiless). ;•.•'•'

Drug^ addiction and drug' 'abuse. In, "The Pharmacological Basis of Thera-
peutics," 3rd edition, Goodman, L. and Gilman, A. (eds.), The MacMillan Co.,
-New York, 1965.

' Narcotic analgestics. In "The Pharmacological Basis of Therapeutics," 3rd
edition, Goodman, L. and Gilman, A. (eds.). The MacMillan Co., New York, 1965.

The rapid development of physical dependence on barbiturates, (with S. K.
Sharpless) /. Pharmacol, and Exper. Ther., 150 :140-145, 1965.

Changes in CNS sensitivity to cholinergic (muscarinic) agonists following
withdrawal of chronically administered scopolamine. The Pharmacologist 8 :199,
1966 (Abs.) (with M. J. Friedman).

The electrical excitability of isolated cortex during barbiturate withdrawal,
(with S. K. Sharpless) J. Pharmacol, and Uxper. Ther. 151 :321-329, 1966.

Research on newer methods of treatment of drug dependent individuals in
the U.S.A. Proceedings of the Fifth International Congress of the Collegium
International Neuropsychopharmacologicum, Washington, D.C., Excerpta Medica
Intern ational Congress Series, 129 :271-276, 1966.

Cyclazocine, a long acting narcotic antagonist : its voluntary acceptance as a
treatment modality by ambulatory narcotics users. Xwith L. Brill) Internat. J.
Addictions, 1 :99-123, 1966. o-'-'^i'

The use of ion-exchange resin impregnated paper in the detection of opiate
alkaloids, amphetamines, phenothiazines and barbiturates is urine, (with Dahlia
Kirkpatrick) Psychopharm. Bull., S :, No. 4, 49-52, 1966. ■

The relevancy of some newer American treatment approaches for England,
Brit. J. Addict., 62 :375-386, 1967 (with L. Brill). . .

Cyclazocine in the treatment of narcotics addiction. In. "Current Psychiatric
Therapies," Masserman, J. (ed.), Grune and Stratton, New York, 1967.

Pharmalogical denervation supersensitivity in the CNS : A theory of physical
dependence, (with S. K. Sharpless) In, "The Addictive States", Wikler, A. (ed.),
The V\'illiams and Wilkins Co., Baltimore, 1968.

Narcotics in the treatment of pain, Med. OUn. North Am,., 52 :33-45, 1968.

Drug addiction : New approaches to an old problem. Postgrad. Med., 45 :73-81,
1968 (with J. Skom and J. Hastings).

Opiate dependence and the use of narcotics for the relief of pain. In, "Modern
Treatment", Wang, R. (ed.), 5 :1121-1135, 1968. ^

Psychopharmacology and opiate dependence. In, " Psych opharmacology : A re-
view of Progress, 1957-1967," Efron, D. H., Cole, J. O., Levine, J., Wittenborn,
J. R. (eds.). Proceedings of the Sixth Annual Meeting of the American College
of Neurophyschopharmacology, San Juan, Puerto Rico, December, 1967.

Cannabis (marihuana). In "Encyclopedia Americana," Grolier, N.Y., 1969.

Drug addiction and drug abuse. In, "Encyclopedia Americana," Grolier, N.Y..
1969.

A review of the approaches to the problem of compulsive narcotics use. In,
"Drugs and Youth", Wittenborn, J. R. ; Brill, H. ; Smith, J. P. ; and Wittenborn, S,
(eds.), Charles C. Thomas, Springfield, 1969.

238

A central hypothermic response to pilocarpine in the mouse. J. Pharmacol, exp.
T/ier., 167:34-44, 1969 (with M.J. Friedman (1)).

Central nervous system supersensitivity to pilocarpine after withdrawal of
chronically administered scopolamine. J. Pharmacol, exp. ther., 167:45-55, 1969
(with M. J. Friedman (1) and S. K. Sharpless). .

Pharmacological approaches to the treatment of compulsive opiate use : iheir
rationale and current status. In, "Drugs and the Brain," Black, P. (ed), Balti-
more, 1969. ^ ,.^ ^ ^u

Experience with the use of methadone in a multi-modality program for the
treatment of narcotics users. Internat. J. Addictions, 4 (3), 481-i90, 1969 (with
M. Zaks and E. Washington).

Problems in Drug Abuse Education : Two Hypotheses. In, "Communication and
Drug Abuse: (with D. Deitch)." Proceedings of the Second Rutgers Symposium
on Drug Abuse, Rutgers University, New Brunswick, New Jersey, 1969.

Tetrahydrocannabinol: neurochemical and behavioral effects in the mouse.
Science, 163, 1464-1467, New York, 1969. (with Holtzman, D. (1) Lovell, R. A.,
and Freedman, D. X.).

The treatment of drug abusers. In, "Principles of Psychipharmacology", Clark,
W., and del Guidice, J. (eds. ) , Academic Press, New York, 1970.

Whatever Turns You Off. Psychology Today, 3, (12), 42^4, 1970.

A comparison of dl-alpha-acetylmethadol and methadone in the treatment of
chronic heroin users: a pilot study. JAMA, 211 (11), 1834-1836, 1970 (with C. R.
Schuster, B. Smith, and P. Blachly).

The implementation and evaluation of new treatments for compulsive drug
users. In, "Advances in Mental Science II — Drug Dependence" Harris, R. T. ;
Mclsaac. W. M. ; and Schuster, Jr., C. R. (eds.). University of Texas Press,
Austin, 1970.

Narcotic Analgesics. In, "The Pharmacological Basis of Therapeutics", 4th
Edition, Chapter 15, Goodman, L. and Gilman, A. (eds.). The MacMillan Com-
pany, New York, 1970.

Drug Addiction and Drug Abuse. In, "The Pharmacological Basis of Thera-
peutics", 4th Edition, Chapter 16, Goodman, L., and Gilman, A. (eds.). The Mac-
Millan Company, New York, 1970.

Further experience with the use of methadone. International Journal of the
Addictions, September 1970.

Development of a successful treatment program for narcotics addicts in Illinois.
Chapter 3, In, "Proceedings of the Second Western Institute on Problems of Drug
Dependence", Blachly, P. (ed.).

Drug maintenance and antagonists : limits and possibilities. Proceedings of the
November 24, 1969 Conference of the New York State Narcotic Addiction Control
Commission.

An identification of techniques for the large scale detection of Narcotics, bar-
biturates, and central nervous system stimulants in a urine monitoring program.
In Abstracts of the Academy of Pharmaceutical Sciences, (117) with K. K.
Kaistha.

An overview of the conference. Proceedings of a Conference on Methodology on
the Prediction of Drug Abuse Potential, Washington, D.C., September 8-10, 1969.
U.S. Government Printing OflBce.

In press

The heroin copping area : a location for epidemiological study and interven-
tion activity. Archives of General Psychiatry , (with Pat Hughes).

Developing in-patient services for community based treatment of narcotic
addiction. Archives of General Psychiatry, (with Hughes, P., Chappel, J.,
Senay, E.).

Methadone and 1-Methadyl Acetate in the management of narcotics addicts.
JAMA, (with E. C. Senay).

Effects of variation of methadone dose on the outcome of treatment of heroin
tisers, Proceedings of the Annual Scientific meeting of the Committee on the
Problems of Drug Dependence. February 16. 1071. (with S. DiMonza).

Experience with eyolnzocine in a nuilti-modality treatment prosram for nnr-
cotics addicts. International Journal of the Addictions, (with J. N. CbappeU
E. C. Senay).

239

Submitted or accepted for publication

Role of hospitalization in tlie treatment of drug addiction, (with J. N.
Chappel).

A double-blind controlled study of cyclazocine in the treatment of heroin
users, (with J. N. Chappel).

Extraction and identification techniques for drugs of abuse in a urine screen-
ing program. Presented to the Annual Scientific Meeting of the Committee on
Problems of Drug Dependence, Toronto, February 16, 1971, (with K. K. Kaistha).

In preparation

Successful withdrawal from methadone : a 1-year follow-up.

Minimal methadone support for narcotics addicts awaiting entry into a com-
prehensive addiction rehabilitation program.

(A brief recess was taken. )

Chainnan Pepper. The committee will come to order, please.

Our next witness is Dr. Harvey Gollance, assistant director, Beth
Israel Medical Center in New York City, with specific responsibility
for the center's narcotic programs.

Before assuming his present position, Dr. Gollance was deputy
commissioner for operations of the New York City Department of
Hospitals, in which post he was in charge of operations at 19 munici-
pal hospitals.

He has also served as supervising medical superintendent of Kings
County Hospital Center.

Dr. Gollance is a fellow of the American College of Hospital Admin-
istrators and the American Public Health Association.

Dr. Gollance has had extensive experience in narcotics treatment
programs, and is a member of the narcotics register advisory commit-
tee of the New York City Department of Health and the methadone
evaluation committee of the Columbia University School of Public
Health and Administrative Medicine.

Dr. Gollance, we are grateful for your appearance here today.

Mr. Perito, will you inquire ?

Mr. Perito. Dr. Gollance, I understand you have a statement which
you are going to offer for the record and briefly summarize.

STATEMENT OF DR. HARVEY GOLLANCE, ASSOCIATE DIRECTOR,
BETH ISRAEL MEDICAL CENTER, NEW YORK, N.Y.

Dr. Gollance. I would like to make a brief statement.

I know you have heard a lot about methadone. We run the largest
methadone program in the world. We are pioneers in this. The Beth
Israel Medical Center is the largest voluntary hospital for the treat-
ment of narcotics addiction in the world. We have 350 beds for nar-
cotic addiction treatment. We admit over 9,000 patients to our detoxi-
fication service, and over 3.200 patients are under active treatment in
our methadone maintenance program.

We sponsor this program in 12 other hospitals in New York City,
some of the most outstanding hospitals in the world.

I would like to start with a brief statement of how the methadone
treatment program came into being, because I think this is important.

We have had very serious heroin addiction in New York City for
over 20 years. It struck in the low-income areas of the city, Harlem,

240

South Bronx, Bedford-Stuyvesant, and it was different from any
addiction problem we had had before. Formerly addiction was some-
thing among doctors, nurses, people of some means.

In the early 1950's a demand arose that the city do something about
it because they had practically no facilities for the treatment of drug
addiction.

In response to this demand, the city did several things. It opened
a hospital for drug users called Riverside Hospital and in its early
years an earnest attempt was made with psychologists, psychiatrists,
social workers, et cetera. The board of education opened a school and
supplied an interested faculty. irOM*^

Riverside Hospital was opened in 1953. :

In 1958, the health commissioner of the State of New York wanted
to see what the State was getting for its money, and he had the Colum-
bia University School of Public Health do a survey of the patients
who had been in Riverside Hospital, and they took a certain time
period and then tracked down the cases treated in that period, 1955,

What this study found was an unusually high death ra-te ; but of
those who survived, none were off heroin. It was obvious Riverside
Hospital was a failure as far as getting anybody free of heroin. It
did give some social first {lid, a chance to reduce dope and stay away
from the police. It is obvious there was no single treatment allowed for
hard-core heroin addiction, , , r 'l, 'iroll-yt Si ^r /^•ji-pilU •- > .iii

In 1963, the health research council of New York City got Dr,
Vincent Dole, later joined by Dr, Nyswander, to do research in the
treatment of drug addiction; Dr. Dole went on the assumption that
whatever the psychological or sociological reasons that a person be-
came addicted, once he was thoroughly addicted there was a physio-
logical change and unless he did something about this he would not b^
able to rehabilitate the patient, the hard-core heroin addict, . .( ;

Dr. Dole's goal was rehabilitation. By that he meant the addict
could function in our society as well as he was capable.

Dr. Dole tried several things. He tried to see if he could stabilize
a patient on morphine, some other narcotics. It didn't work. Then
he used methadone in a new way. It is a synthetic narcotic that was
used in World War II by the Germans, when their supply of opium
was cut off.

After the war methadone was used mostly for the detoxification
of patients — to get them drug free in a humane way instead of suffer-
ing throuerh "cold turkey." In a week you can get any heroin addict off
heroin. The point is the addict won't stay off heroin. Dr. Dole wanted
to see what would happen if instead of reducing the dose of methadone
as in detoxification, he gradually increased the dose. He foimd two
things : Wlien a certain level was reached the addict lost his drug hun-
ger. He no longer had any craving for heroin, and if you went to a
still higher dose it blocked the effect of heroin.

Dr. Dole got pure heroin and .eventually injected Inr.o-e quantities
of heroin into patients on blocking doses of methadone. Xothiiig hap-
pened. This is called the blocking effect.

When we speak of the methadone maintenance treatment program
we mean the Dole-Nyswander technique of givmg blocking doses of
methadone — not just giving methadone in any haphazard sort of way.

■ Methadone has properties that make it very useful for this woik. It
is fully effective by mouth, it is long acting; once you get a patient
stabilized, a single dose by mouth will last him 24-36 hours. It is a
safe drug. .a^j'-r ;->,>■. .

We haven't had any serious harmf ill' effects either medically, sur-
gically, or obstetrically in 7 years. The body develops great tolerance
for methadone in a relatively short tima It no longer acts as a nar-
cotic. By that I mean it does not make the patient high and it doesn't
make him sleepy. It is, however, addictive. If taken away from the
patient he would have withdrawal symptoms. '• ' ■

Dr. Dole did this work with six cases at Rockefeller Institute and
then came to Dr. Ray Trussell, who was then commissioner of hospitals
in New York City, and asked for facilities to expand his work.

Through Dr. Trussell 's efforts, Dr. Dole got the beds in what is now
the Beth Israel Medical Unit for Drug Addiction. We inaugurated
this program in 1965.

When Dr. Trussell set this program up, he insisted that a separate
contract be given to the Columbia University School of Public Health
to do an independent evaluation of what happened to every patient in
the methadone program. This is important. We now have records of
every single patient who has ever come into our program, and these
results have been independently evaluated by the Columbia University
School of Public Health. .i^i"bji bsmiiiuor) a >.i nn-nU]

If we are going to get ahywh'er^'in treafm'g driig addiction we must
know what works and what doesn't work. T think this independent
evaluation is an important part of this program. ,»it/.)!^'

- Originally the patient was taken into the hospital for 6 weeks. After
he was stabilized, he was sent to a clinic with a number of supporting
services : counselors, research assistants, social workers. The goal is re-
habilitation, not just to satisfy the drug hunger. .ip/iwrr:,
J Many of our patients started- very young. You now have help for
them with all their problems, help them with welfare, with the courts,
with their wives, get a job, all of these things. -You must help to get
the patient intothe square society f' if^^"' '^fut.'/ '.v^jiyrf o1 ojJIi [t

We do this. We believe that a methadone hlaiTitenarice program
should be done in a structured program. You must know whtit hap-
pens to your patient, and you work intimately with him. ■
_ As a matter of fact, we don't let an individual clinic exceed 150 pa-
tients. We want the staff to know the patient well and what is happen-
ing to him. At the present time we have almost 40 clinics scattered
throughout the New York City area. ; . ".i

When we reach a census of 150, we open a new' clinic. Wedobkat
the addict as an individual with a chronic illness. He is a m.edical pa-
tient. We base our program on a hospital. IMost all our clinics are out in
the community. They are considered an extension of the hospital. We
think this philosophy of medical en re is important.

Addicts have other problems besides their addiction. They have
medical problems. The medical profession has shunned treatment of
drug addiction for a number of generations now. In the past it was
too dangerous for a doctor to deal with drug addicts. He risked prose-
cution and possible jail.

We now have a medically based program with a hospital to take

242

€are of patient addicts. We have seen some very interesting byprod-
ucts of this other than the direct treatment of addiction. We find out
that when we set up a clinic associated with a hospital, the medical
staffs become interested in treatment of drug addiction. If we are go-
ing to get anywhere in this field we need to bring the best brains we
have into solving this difficult problem. Methadone maintenance has
set up a climate favorable for this.

Methadone is not the final answer. It happens to be the best answer
we have at this time for treatment of the hard-core heroin addict.

Dr. Dole's original criteria were that the patients had to be 21 years
of age and under 40, because there is a theory around that drug addic-
tion burns itself out as the patient gets older.

They had to have a history of mainlining heroin. They were hard-
core addicts. They all had criminal records and had tried other pro-
grams without success, to further confirm their serious addiction.

The original program, because it was new, excluded certain condi-
tions: alcoholism, pregnancy, mixed drug use. However, as we have
gained much experience we have broadened the criteria for admission.
We admit now a patient over the age of 18, there is no longer an upper
age limit. We have one man 87, one 82, and a number collecting social
security.

We now require 2 years of heroin addiction. We are very careful to
see that the applicant is a confirmed addict.

This is a voluntary program. In our experience it takes about 2
years before a heroin addict is first willing to do something about his
addiction. At the beginning the drug addict rather enjoys the high
he gets. He is a very busy individual supporting his habit by stealing.
He rather enjoys that culture at the beginning. We feel it takes 2 years
before he is willing to do something constructive by entering this
program.

For this group of cases, this program has proved very successful. I
believe you heard Dr. Gearing. She does our evaluation. She is a very
competent individual.

I would like to review what our experience has been. Basically we
liave an 80-percent retention rate in the program. We have a 20-per-
cent dropout rate. Very few of the patients drop out of their own voli-
tion. They are usually dropped out by us for administrative reasons.
These turn out to be severe alcoholics, a few get arrested early in the
program or use other drugs.

The work records are very interesting. I don't have the most recent
figures. I don't know what ejffect the present recession will have. Up to
about a year or two ago our patients were about 25 percent legit-
imately employed when they started. At the end of 6 months, about 50
percent are working and after 2 years 80 percent. For those in the
jDrogram 3 years or longer, 92 percent were either working, keeping
house, or going to school, and only 6 percent were left on welfare.

Tlie arrest records in our program have been phenomenal. Dr. Gear-
ing did a study of arrest patterns. She took a group before they came
into the methadone program and studied their arrest records. It showed
115 arrests per 100 patients in the course of a year, 48 convictions per
100 patients in the course of a year. She then followed the course of
these patients for 4 years after they started on methadone.

2fi3

The 115 arrests per 100 per year dropped to 4.5. The 48 convictions
dropped to 1 per 100 per year. The arrests practically disappear and
the longer in the program, the fewer the arrests.

Here was a program that took hard-core heroin addicts whose treat-
ment had been very unsuccessful before. I, myself, when I was deputy
commissioner of hospitals, tried setting up programs, pleading with
doctors to set up programs. I was not successful. The few programs in
existence were very unsuccessful and most physicians I knew were
very discouraged.

Now, we take a large number of severe heroin addicts and you have
them working, you keep them out of jail, you put tlieir families to-
gether.

That doesn't mean we have all angels in our programs. "We have
some who have problems. Some will do things they shouldn't, but on
the whole this has been a very successful program.
With that introduction, I would like to answer some questions.
Chairman Pepper. That is a very good summary.
Dr. GoLLANCE. Could I answer the previous question about dispens-
ing it ?

I would be against dispensing it just in pills. We have changed over
to what we call a disket. It is a large tablet that leaves a sludge, and
the patients can't inject it. We use diskets to prevent careless handling
so that children can't get them.

For this reason we have a tendency to use diskets dispensed in vials

with locking caps where they can be kept in the medicine chest away

from children.

Mr. Brasco. That is the question I asked. Doctor.

Do you agree with Dr. Jaffe, then, of the impracticality in New

York of having a patient come once a day for his dosage rather

than

Dr. GoLLANCE. Yes; when you are on a very large scale program.
Mr. Brasco. So you agree ?

Dr. Gollance. Yes ; and for the reason Dr. Jaffe said, we are trying^
to rehabilitate patients.

Mr. Brasco. The disket is something that cannot be injected; is
that correct ?

Dr. Gollance. That is correct.

Mr. Brasco. I was concerned about working with substances that
would be practical for carrying and used just as long as they could
not be used intravenously.
Dr. Gollance. That is right.

Mr. Brasco. But that disket is not something capable of being used
intravenously ?

Dr. Gollance. That is correct. I would like to answer Congressman
R angel on the ethnic distribution of patients in New York. We have
a narcotic registry run by the health department and the ethnic dis-
tribution of their list is 50 percent black, 25 percent white, 25 percent
Puerto Rican.

The patients in our programs approximate that ethnic distribution.
I would also like to say that this is no longer a situation of the low-
income group. Last week the daughter of a prominent professor and
the son-in-law of a prominent head of surgery in one of the leading

244

hospitals in the city, came into our program. In answer to your ques-
tion, two marines I know personally came back addicted. The reason
the marines snort heroin and don't inject it is so they won't leave
trackmarks. But when they come back here they will start injecting
heroin. This one Marine had gotten $6,000 from an automobile acci-
dent and wanted to return to the Orient for drugs. I got him into the
methadone program and he is doing very well, u; ruoiu i

Chairman Pepper. Mr. Perito, please proceed.

Mr. Perito. Thank you, Mr. Chairman.

First, Doctor, do you believe that private physicians should be per-
mitted to maintain addicts on a maintenance program ?

Dr. GoLLAxcE. At this time I would say no. Our feeling is that this
should be done in a structured program. We have given a lot of
thought to how to use private practitioners. For example, if we had a
well-stabilized patient he might be referred to a private practitioner.
If this were done, it would furnish a means of having the patient
checked, because there is possibility of abuse.

There is the program in New York City that disburses

Mr. Pertto. You mean dispensing of methadone by a private physi-
cian ; is that what you are talking about ?

Dr. Gollance. That is right.

Mr. Perito. What steps can be taken in order to avoid problems
of this nature ? , "' ' ^'''^ ^'^^^-'^ ^^''^ ■' '^ ' f^'^ ^ '•! i J o^

Dr. Gollance. Well, the thing is if you can set up enough programs
so the patient can come in and get it from established programs very
cheaply and receive good care. We g&t many patients from this private
doctor when we can reach him on our list. '^-^ ''^- ' "''' ^ ■o.iPj.i,:>. i .^i/:

Unfortunately, we have quite a long waiting list. The last time T was
before this committee, we were asked how can we expand the program.
I might say, since that time last year, we have taken as many patients
in 1 year as were taken in all of the previous 5 years. We have the
mechanism for expanding this widely if' we get the necessary funds

Mr. Perito. Do you believe addiction is a metabolic situation ?

Dr. Gollance. I think you have to make that assumption. At least
it has worked here. The psychological and sociological apiproaches
have not worked for this type of patient. We have tried all these
things without methadone and they haven't worked. Under methadone
you can use a number of successful aLppjcoac.hes, but without it we have
been very unsuccessful. 'c. ..,. ^.i. _ii;

Mr. Perito. What steps have you taken in your program to control
diversion?

Dr. Gollance. First of all, we limit the size of the clinic so we
know the patient. We constantly watch the patient, besides the urine
checks, to know that he is not using Other drugs, and if we have any
suspicion at all we will put him on a daily regime.

One of the interesting tilings is the patient develops a loyalty to tlie
program. I know addicts are not supposed to squeal, biit tliey will
come to us and toll us. look out for this f'^How. and avo will. Thoy will
give us information about our patients. We have a patient-phvsician
relationship. We don't take a punitive approach. We don't look at the
addict as a dope fiend or outcast. We encourage him to tell us when
he is abusinc:. In the first few weeks he will.

245

If he is using other drugs we will ask him to tell us so we can work
with him.

Mr. Perito. Finally, Doctor, to the best of your knowledge, is there
a black market for and in methadone in New York City?

Dr. GoLLANCE. I am sorry to say there is. We have asked the police
repeatedly, ever since we have had the program, do they thuik our
program is a problem for them.

Tliey have told us our program is not. But we do know it is getting
on the*^ streets from some very unstructured, unsupervised programs.

I appeared before a group of probation officers and a police officer,
and he said, "I know it gets on the street." I said, "I would like to see
it. I don't think it is any of ours." He pulled out a vial and there was
a label of this unsupervised program in New York City.

Chairman Pepper. Mr. Blommer.

Mr. Blommer. I have no questions, Mr. Chairman.

Chairman Pepper. Mr, Waldie.

Mr. Waldie. No questions.

Chairman Pepper. Mr. Wiggins.

Mr. Wiggins. Would you describe the workings of the central regis-
try for us ?

' ! Dr. GoLLANCE. The health department gets all the information.
Physicians are supposed to report to them and it is strictly confiden-
tial. I would say most of their records are gotten through arrest
records. When arrested, that is reported to the central registry. Also,
physicians and others with knowledge are required to report this to
the health department.

Incidentally, Dr. Dole has been working on detoxifying prisoners
in the New York City prison and at nights I have personally observed
that at least two-thirds of the prisoners are addicts under the influence
of heroin.

Mr. Wiggins. Can you describe the methadone registry for the
record?

Dr. GoLLANCE. That is a special methadone registry under the di-
rection of Eockefeller University. This registry for the methadone
patients is available to Dr. Gearing and Dr. Dole at Rockefeller. Any
patient we treat, or any hospital connected with us must report every
patient into this central computer. We finance and train hospitals.

One thing that we will not yield on in any way is that they must
report in their results in exactly the same manner as we do. There is
standardized reporting in our program.

However, there are programs that do not report to this central
registry.

Mr. Wiggins. That is all.

Chairman Pepper. Mr. Brasco.

Mr. Brasco. Yes. Could you tell us, Doctor, how long is the waiting
list for the program ? -.iuAj-"ji\r nfi : .■

Dr. GoLLANCE. It varies. It used to be very long. It has gotten much
shorter. We have set up a number of programs, including what we call
rapid induction. We are working now on what we call a holding pro-
gram. That will cut down waiting time. It varies from weeks "to
months, depending on the area in which the patient lives.
;;Mr. Brasco. That is another thing. I know it is localized. Coming
Irom- New. York, I had an opportunity to try to place a young man

246

that came into my office, and I was sort of distressed to find out that
the program he was talking about had longer than a 5-month waiting
period and over and above and beyond that there was this geographic
thino- where they said we don't service that particular area.

Apparently what had happened is one program that had some open-
ings said we don't service that area and the other program said we
don't service that program.

I thought it was all your program. ^

Dr. GoLLAXCE. No ; there are a number of programs m New York
City. We are in four boroughs. We have others besides ours. The city
has opened up several, the Bronx has a separate program.

In our own network we have 14 hospitals, 30 clinics, and 3,200 pa-
tients. If we get the funds, we will go to 6,000 patients. We have the
means now to expand. We have trained staff to act as a nucleus for
expansion. It is not only a matter of money. It is to get space, to train
stall's, to get people willing to do this work. I think we are over most
of that hurdle.

Mr. Brasco. You say you have the means. You say you have 3,200
patients. What does that mean ? How many patients can you convert
if you have the money and you have the staff ?

Dr. GoLLANCE. They have been making funds available now and
more and more are getting into

Mr. Brasco. How many additional patients would that be ?

Dr. GoLLANCE. If we get what we ask for from the State — for ex-
ample, we are financed entirely by the New York State Narcotics Ad-
diction Control Commission — if they give us the funds we will jump
from 3,200 to 6,000 this year. That is just our program.

Mr. Brasco. One last question.

The diversion of methadone, when it is diverted in the streets, it is
used, I take it, as a substitute for heroin, mainly because it is cheaper ;
is that the reason ?

Dr. GoLLANCE. From what I gather from all the addicts I have
spoken to, they do not take methadone as a drug of choice. After he has
become addicted, after a while, the addict is not looking for the highs.
He is looking to be comfortable. He doesn't want to be sick. Methadone
will prevent him from getting sick.

Mr. Brasco. So that what you are saying^ then, is that the addict
that is using this in the street, when methadone is diverted, is using it
in the same way that he would use it in your program, other than the
fact that it is

Dr. GoLL.\NCE. He is trying to do it that way by and large. There
are a number of psychotic individuals around. For example, our ex-
perience has been that anybody who takes heroin after 8 weeks in our
program, usually turns out to have a serious psychiatric problem. He
doesn't get any high from it. He is a needle addict.

Mr. Brasco. I have no further questions.

Chairman Pepper. Mr. Steiger.

Mr. Steiger. No questions.

Chairman Pepper. Mr. Mann.

Mr. Mann. Qualified personnel is a problem in the expanding medi-
cal field. How about your problems ?

Dr. Gollance. Well, there has been a great improvement in our
program. For example, we are getting young doctors now who are

247

interested, and I have applications from doctors to join the program.
I don't have spots for them right now. The nurses enjoy doing this
work. We are one of the few programs that doesn't have difficulty
recruiting nurses.

The counselors are flooded with requests from bright young people
now because of the job situation and we can get a good calibre of
counseling. We are not having problems getting personnel that we
had, maybe, 2 years ago, 3 years ago.

Our problem now is boiling down to money.

Mr. Maxn. To what extent do you use ex-addicts in your program ?

Dr. GoLLANCE. We use ex-addicts. We call them research assistants.
They are a very valuable part of the program. We have a very limited
number. In our requirement we will not take an addict right from
our program and hire him as a research assistant. He must get a job
and show he can hold a job on the outside. When he does, we can hire
him. They are very useful, they are useful as a model to the new patient
in explaining the program to the new patient, useful in explaining the
addict to the "square" staff that we hire. So they are very, very useful.

Mr. Mann. Thank you.

No further questions, Mr. Chairman.

Chairman Pepper. Mr. Winn.

Mr. Winn. Along that same line, what difficulties have you en-
countered in obtaining physical facilities for treatment of the addicts ?

Dr. GoLLANCE. We have had many problems in that area, and we
use any physical facilities we can get. We use stores, brick them up.
We don't call them storefronts because our addicts have had bad ex-
periences with storefronts. We use health buildings, office buildings.
We even set up a program in a church and are looking at another
church to get space. So we will use available space.

Now, there is a problem in getting space. We go into a community
and try to see if the community is going to back this program. They
are very much in favor of it but don't want it on their block.

So we have worked that out.

In the Harlem cormnunity, fortunately, we don't have that problem.
We have been able to open up a great many clinics and we are expand-
ing there.

But in certain other areas, it is a problem.

Mr. Winn. Do you use the residential system Dr. Jaffe referred to ?

Mr. GoLLANCE. No ; we haven't done that. Practically all our patients
are treated on an ambulatory basis. We have a certain number of beds
for those who have difficult problems and we will take them into the
hospital for 6 weeks.

We also have a medical service and obstetrical service to take care of
the patients.

I would also like to touch on that because this comes up. We think
it is important for the pregnant addict to be stabilized on methadone.
Our experience is that the pregnant woman stays on the street as long
as she can. She is a prostitute, gets no prenatal care, takes a shot of
heroin and tries ta smuggle some heroin in with her when she enters
the hospital for delivery. At least on methadone maintenance they
get prenatal care, we can follow them carefully, and I might say that
methadone has brought about a great change in climate. When I was

248

deputy commissioner of hospitals, it was recognized that pregnancy
in addicts was a problem. , i

We approached the chiefs of the obstetrical services and almost to
a man they said this is not their problem. Now, our obstetricians see
these cases. They are much interested in them and there is a much
better climate for the. pregnant addict than what existed 5 or 10 years

Mr. WioGiNS. Incidentally, does 'the child manifest withdrawal
symptoms?

Dr. GoLLANCE. We have watched them very carefully. We are going
to follow those infants for a long time. But the alternative would be
they would have heroin withdra,wal symptoms. ■ '. i

Chairman Pepper. Doctor, I have to go to the floor for a little while.

I will ai^k Mr. Walrlie if he will be good enough to take. the Chair.

I will ask you one question and make one comment..! iiL-o oi \

How is your program financed ? > ot/j ^oiijj'rt'p.rr vth e-ij; i :

Dr. GoLLANCE. Entirely by New York State Addiction Control
Commission, and we are worried very much about future financing.

Chairman Pepper. Secondly, on behn.lf of the committee I want to
express our very deep appreciation for your coming here and giving us
the benefit of j^our knowledge and experience.

Dr. GoiXANCE. Thank you. It is a privilege to. be here.

Mr. Waldie ( presiding) . IMt. ISIurphy. q 'jn'r
' Mr. Murphy. Yes. ii biifi 'jvorf

What experience do you know of that the Army has had with
methadone?

Dr. Gollance. I don't' know the Army's experience. I know the
veterans hospitals in our area have been very interested. I have spoken
to two of them. One of them is setting up a program. I would think
that this is a very serious problem. I am not an expert on the Army's
situation. q aiiH :;loj;J ot Bfiioi>. • /nmo'. sdi i vij i> v

I had one nian tell me the main reason for reenlistment in a certain
group was to stay in the Orient where they could get heroin.
" Mr. Murphy. That is all. - ,, ; ;

Mr. Waldie. Mr. Eangel. iiii /• qir k

Mr. Rangel. Do you know of any feasible way to dispense methadone
in such a form that it cannot be reduced to another substance so that
it can be used intravenously ? . ;> -

Dr. GoLLANCE. Well, if it is given dissolved in Tang, as we do, or
in disket form it can't be injected. - . > .j^i. . vi;.

Mr. Rangel. But we discussed tMte earlier 'aiid determined that it
was not practical to do this. Is there any other form, concrete form,
that you can create a methadone treatment or dosage so that it would
be impossible for the patient to later reduce it for injection?

Dr. Gollance. Well, I don't think they can reduce either of these
two forms we use. The type they inject are the pills usually gotten
from physicians. They are the usual* medical tablets and they are in-t
jectable. Perhaps do away with the injectable pills might be one way.

Mr. Rangel. Are you saying that in your treatment program you
don't give methadone in any solid form at all? if^b 7o'1 [■>;<!-»;[ ^(Fi

Dr. GoLLANCE. Only in this disket which is a sj^ccial form, certain
substances are put there so it leaved a sludge so it won't go through a
needle.

249

Mr. Hangel. That is a solid form ?

Dr. GoLLANCE. It is a solid tablet. It is dissolved in water. It is like
a large Alka-Seltzer and it fizzes up and it leaves a sludge and they
drink it when dissolved.

Mr. Eangel. If all of methadone was required by law to be dis-
pensed only in the form in which you dispense it, would that not
eliminate the possibility of injections ?

Dr. GoLLANCE. Yes ; and I might point out that methadone is a diffi-
cult drug to synthesize. There is only one manufacturer that I know
of in thi^ country, so it is not the type of drug that you can bootleg
and make it surreptitiously.

]\Ir. Rangel. Thank you.

Mr. Waldie. Thank you.

Are there any other questions ?

Doctor, we appreciate very much your appearance before the
committee.

(The following material was received for the record from Dr.
Gollance:)

[Exhibit No. 13(a)]

Methadone Maintenance Treatment Program

(Reprinted from Maryland State Medical Journal, November, 1970, Vol. 19, pages
74-77. © 1970 by the Medical and Chirurgical Faculty of the State of Maryland, Baltimore,
Maryland. Printed in U.S.A.)

By Harvey Gollance, M.D., Associate Director, Beth Israel Medical Center,
Administrator, Methadone Maintenance Treatment Program, New York, N.T.

Drug afldiction has reached epidemic proportions in Isfeio York City and in
other sections of the United States as well. An effective treatment for severe heroin
addicts known as the methadone maintenance treatment program has ieen
developed at Rockefeller University and has continued in a greatly expanded
program at the Beth Israel Medical Center in New York.

Facilities for the treatment of narcotic addiction were almost nonexistent in
New York until the 1950's. It was then that the increase in the number of addicts
in the low-income areas was recognized, as was the increase in the use of nar-
cotics by the young. Concerned city authorities prompted the department of
hospitals to establish facilities for adolescent drug users. As a result, a 140-bed
hospital. Riverside Hospital, was opened in 19.52. Psychiatrists and strong re-
habilitative and supportive services were provided. In addition, beds were ob-
tained in a proprietary hospital. Manhattan General Hospital, to detoxify nar-
cotic patients. With one exception, the chiefs of service of the municipal general
care hospitals resisted the treatment of drug addicts in their service. Few physi-
cians were interested, and almost all refused to treat the addicts.

A study was done by Columbia University in the late 1950's of 248 patients
discharged from Riverside Hospital. It showed that almost 100 percent of the
patients still alive became readdicted shortly after discharge. Ray E. Trussell,
M.D., director of the School of Public Health and Administrative Medicine of
Columbia University, during a sabbatical leave, had been appointed commis-
sioner of hospitals of New York City in 1961. Dr. Trussell, as a result of the
Riverside Hospital study, and because of additional serious administrative
problems, decided that Riverside Hospital should be closed, and that we should
seek new approaches to treat drug addicts. Riverside Hospital was closed in
196.3. Although it had given its patients some social assistance, it failed both in
preventing readdiction and in rehabilitating its patients. It seemed clear that
the answer to the treatment of narcotic addiction lay in new directions to be
determined by future research.

research encouraged

The Health Research Council of New York City was interested in encouraging
research in the area of drug addiction, and in 1963 they initiated a grant to

60-296—71 — pt. 1 17

250

two Rockefeller Institute physicians: Vincent Dole, M.D., a specialist in meta-
bolic research ; and Marie PI Nyswander, M.D., a psychiatrist with long experi-
ence in drug addiction.

Dr. Dole and Dr. Nyswander attempted to find a means of treating a patient
which would enable the patient to function productively in society. The research-
ers considered drug addiction as a psychological disorder and thought it reason-
able to ask whether some medication might control the drug hunger. At first
they attempted to maintain patients with morphine. While this did away with
much of the patient's antisocial behavior, it did not make him productive. Next,
they used methadone in an unusual way, giving their patients gradually increas-
ing doses until the tolerance level was reached, usually between 80 to lliO
milligrams daily. When patients reached this maintenance level, usually after
6 weeks of treatment, the physicians found that several things happened :

(1) The patient showed no harmful effects from methadone. He was neither
sleepy nor high. Medical examination and all types of medical, physiological,
and psychological testing showed no harmful effects from methadone.

(2) The patient lo:>t his drug hungei*.

(3) The effect of heroin was blocked. Even when given an injection of heroin,
the patient experienced no effects from it.

(4) The dosage of methadone, once established, remained stable. It did not
have to be increased, and was long acting (24 to 3G hours).

GROWTH OF THE METHADC>fE PROBLEM

After intensive study and experience with six patients. Dr. Dole went to Dr.
Trussell, showed him the histories of his six patients, and asked for facilities to
expand his work. In 19G5, through Commissioner Trusseli's efforts, beds were
obtained at the Manhattan General Hospital. This hospital of 386 beds later was
acquired and became an integral part of the Beth Israel Medical Center. This
was done through the help and cooperation of the president of the Board of
Trustees of the Beth Israel Medical Center, Mr. Charles H. Silver. In 19GG, the
center was renamed the Bernstein Institute of the Beth Israel Medici^.l Center.
It is the largest center for drug addiction under voluntary auspices. Methadone
maintenance is one of several narcotic programs of the Bernstein Institute.

In 5 years, the Methadone program has expanded to the point where over 1,300
patients are currently being treated in four hospitals and 15 clinics under the
sponsorship of the Beth Israel Medical Center. Several additional voluntary and
municipal hospitals and clinics are now almost ready to join the Beth Israel
Methadone Maintenance Treatment Program. The inpatient phases of the vrork
are done either at Beth Israel or at Harlem Hospital. Clinics have been estab-
lished at Beth Israel Medical Center, Harlem, St. Luke's, and Cumberland Hos-
pitals. In addition, a number of hospitals in New York City have established
their own methadone programs based on the work done previously at the Beth
Israel Medical Center.

This program considers the addict a patient with a chronic disease. The in-
dividual whom it treats is the hard-core addict who suffers from euphoria and
drug hunger, is unable to function socially or economically, and must take drugs
to relieve his physical misery.

Naturally, we realize that it would be best if the cause could be removed and
the patient made drug-free. But all programs which have attempted this in a
community setting have failed. This program deals with the symptoms. The
Methadone blockade against opiates frees the addict from his drug hunger so
that he becomes receptive to rehabilitation. It should be stressed that this
program deals with the long-term, usually ci'iminal addict, who has been unable
to make it in any other way. Our goal is social rehabilitation for those who have
been unable to achieve abstinence.

TREATMENT APPROACH

The Methadone program is not based on a psychiatric approach. While psy-
chiatric consultation is needed for a number of patients, it is not the primary
modality. Our experience has shown that the program is equally effective in a
department of psychiatry, medicine, or community medicine. The important fac-
tor is competent direction by an interested physician. Our experience has also
shown that there should be available good medical and obstetrical services by

251

pliysicians who are familiar with methadone patients and who are available for
back-up in program.

INTAKE OF PATIENTS

A central intake of patients for all the clinics and h-^spitals associated with
this program has been established under the direction of a skilled staff. This
staff has had experience working with addicts, and their backgrounds are essen-
tially in social service. They screen the applicants for acceptability in the pro-
gram. A research assistant (an addict in the program who has proven himself) is
of great assistance in this procedure.

Originally, because this was an experimental program, very rigid qualifications
for admission were established. These subsequent qualifications and their modi-
fications are :

1. Af7e.— Originally, age was set at 21 to 39 years. The patient had to be able
to sign a consent form but could not be over 39 because of the theory that drug
addiction decreases with age. The age requirement has now been changed ro 18
years with proper consent. No maximum age limit now exists. We even treat
patients collecting Social Security, and those registered with medicare.

2. Residence. — ^New York City residency is required because of reimbursement
aspects.

3. Addiction. — Only opiate addicts are accepted. Severe barbiturate an<l am-
phetamine users are rejected, as well as are those with multiple addiction (i.e.,
combination of opiates with barbiturates). Hov/ever, the final decision for accept-
ance may be modified by the clinician in charge.

4. Length of drug use. — Originally, a minimum of 5 years of mainlining heroin
was set. This has been gradually reduced and is now 2 years.

5. Psychiatry. — Any history of psychoses or severe mental disturbance is
usually cause for rejection. This may be modified by the clinician.

6. Addiction in family unit. — If the patient's spouse is addicted, both must be
eligible and admitted together. The same is true of any family members living
in the same household.

7. Alcoholism. — Severe chronic alcoholics are rejected.

8. Mental deficiency. — Addicts are rejected if intelligence quotient is so low
that they cannot handle the responsibilities of the program.

9. Medical. — Cirrhosis of the liver, diabetes, epilepsy, and terminal conditions
were originally reasons for rejection. We now have no medical exclusions.

10. History of previous unsuccessful treatment. — This has now l)een modified,
and a determination is made according to the judgment of intake personnel.

11. Acceptance of patients. — Finally, the physician in charge must approve the
selection of the patient.

PROCEDURE

When it has been determined that the patient meets the criteria and a vacancy
for treatment occurs, he is admitted into a phase I program. Originally, this was
a 6-week period of hospitalization on an open ward. This phase has been modi-
fied and now, in a high percentage of cases, it is done on a strictly ambulatory
basis. The patient is given divided doses at first. As the dosage is increased, and
there are no undesirable side effects, the dosage schedule is changed to a single
daily dose. The methadone is dissolved in an orange juice substitute and taken
orally.

After reaching maintenance level, the patient is next assigned to a phase II
clinic. At first, the patient reports daily. He leaves a urine specimen which is
tested for opiates (heroin and morphine), amphetamines, quinine, barbiturates,
and methadone. He drinks his dose of methadone in front of the nurse, and
periodically reports on his activities (for example, school, work), or problems. As
the staff is convinced of the patient's progress, he is required to report less often —
three times a week, twice a week, then once a week. However, when he does rei»ort,
he drinks that day's dose of methadone in front of the nurse (to be sure that he
is still taking it), leaves a urine specimen, and is given his daily supply of
methadone for those days when he does not report to the clinic.

We try to limit the size of our phase II clinic to less than 100 patients. Each
clinic has a part-time physician, a nurse, or nurses (depending on the hours of
the clinic), a supervisor, counselors, a research assistant (ex-addict), and clerical
personnel. Backup medical, psychiatric, pharmaceutical, social, legal, and other
services are provided when needed.

252

It is during pliase II that serious efforts are made in the rehabilitation of the
patient A wide spectrum of services is offered to the patient in the areas of
medical care counseling on problems of everyday life, social services m regard
to family living and ■community resources, vocational rehabilitation, and legal de-
fense advice. The older patients on the staff are especially helpful in this phase,
and are constantly available to help with problems peculiar to addictive patients.

After a year when the staff is convinced that the patient is doing well, at a
job, at school, 'or at keeping house, and the patient seems to have no problem
with alcohol or drugs, he is assigned to a phase III clinic. The treatment is essen-
tially the same, but the frequency of visits is much shorter and there is little
need for the counseling staff. These services, however, are available if needed.

EVALUATION

From the start, in 1964, this program has had independent evaluation of all
the patients who have ever entered it. Originally, when the city financed this
program, money was allocated to the Columbia School of Public Health to per-
form this evaluation. When financing of the methadone maintenance treatment
program was assumed by the State narcotic addiction control commission in
1967, a separate contract was given by the State to the Columbia University
School of Public Health and Administrative Medicine to continue this evaluation.
A highlevel committee was appointed. The charge to this committee was to
evaluate the results of this program in an objective manner, and to make recom-
mendations based on this evaluation. Frances Rowe Gearing, M.D., was appointed
the director of the evaluation unit.

In their report of March 31, 1968, the committee reached these conclusions :
"The results of this program continue to be most encouraging in this group of
heroin addicts, who were admitted to the program on the basis of precise criteria.
For those patients selected and treated as described, this program can be con-
sidered a success. It does appear that those who remain in the program have,
on the whole, become productive members of society, in contrast to their previous
experience and have, to a large extent, become self-supporting and demonstrate
less and less antisocial behavior. It should be emphasized that these are volun-
teers, who are older than the average street addict and may be more highly
motivated. Consequently, generalizations of the results of this program in this
population to the general addict population probably are not justified. There
remains a number of related research questions which need further investigation."

A report as of March 31, 1969, showed there were 153 women and 861 men who
had been under observation 3 months or longer.

"Among the women, 10 percent were employed on admission. After 12 months,
33 percent were employed. Fourteen percent were homemakers, and 3 percent
were in school. After 18 months, 65 percent were employed, in school, or home-
makers and, after 2 years, this percentage had increased to 73 percent.

"Among the men, tlie percent of those employed or in school increases from
26 percent on admission to 56 percent at 12 mouths, 70 percent at 24 months, and
S3 percent at 3 years. The percent of men on welfare or supported by others de-
creases proportionately from 54 percent at 6 months to 44 percent at 12 months,
30 percent at 24 months, and 17 percent at 36 months.

"The arrest records of those who enter the methadone program and those who
enter our detoxification program are similar. Patients who are accepted have to
wait a long period. Acceptance into the program does not have a marked effect
on their pattern of arrest in the 12 months prior to admission. Following admis-
sion, there is a marked decrease in arrests while the pattern of arrest among
the contrast (detoxification) group is very similar to earlier patterns."

None of the patients who remained in the program have become readdicted
to heroin. Problems with drug abuse (amphetamines and barbiturates) varied
from 4 percent to 12 percent.

The methadone maintenance treatment program is an effective, economical way
of treating hard-core heroin addicts who cannot be treated successfully with any
existing programs. It can now be done on an entirely ambulatory basis for most
patients. This makes the program feasible for those areas where inpatient beds
are difficult to obtain. We feel it is very important that this program be a struc-
tured one so that it i-emains carefully controlled.

Methadone maintenance treatment for heroin addiction is a public health pro-
gram. It should be accomplished under the direction of a public health deijart-
ment, a hospital, or an organized uiodical facility. Since rehabilitation and social
productivity of the patient is the prime objective of this program, it is important

253

that the means to do this must be an integral part of the program. It is not suffi-
cient to prescribe methadone alone.

Under these circumstances, the addict is given a chance in a program which he
is capable of handling, and which offers him a realistic path to living as a respon-
sible member of his community and of society without the crutch of heroin.

Mr. Lichtman, whose statements follow, is a research assistant at the Beth
Israel Medical Center. Before becoming an assistant there, he was a drug addict.
In conjunction with Dr. Gollance's article on the methadone maintenance pro-
gram, Mr. Lichtman tells how the program has helped him.

I am 29 years old. I started using heroin at the age of 15. I used it for a period
of approximately 10 years. Approximately 4 of those years were served as a
guest of the city. State, and Federal governments in any number of institutions.

After a period of 10 years, I found that a strange thing happened to me. I devel-
oped a certain motivation which I had not had during that time. I decided that
I wanted something more than I had had for those 10 years. I came to the Beth
Israel Medical Center in April 1966, at which time I applied for the methadone
maintenance program. The reason that I had originally applied for that program
is that I had unsuccessfully tried other methods of treatment when coming out
of institutions in other programs. I found that the same drug craving which I
liad in going into a program would return upon my release from an institution.

I had heard many stories about methadone. I heard that while taking methadone
you are still addicted, and you would not be able to function in the cuiiim unity.
But I decided that since I had not been able to function in the other prograni.s,
that I wonld try methadone.

As I said, I went into the hospital, and stayed there for a period of 6 weeks,
during which time the metl'adone level was increased.

After leaving the hospital, I returned to my family, who were skeptical. My
father owns his own business in Manhattan. He is a furrier and does make a
good living. During the 19 years I was using drugs, he did not allovs- me into
his place of business. When I returned there from the methadone program, as
I ?aii\. he was skeptical, but was willing to take a chance with me.

I lived at home for 4 months, at which time I met a young lady who was
also willing to take a chance with me and who knew my background. After
about 6 months, we were married.

I now have a lovely home in Riverdale, and a new car. I work for the pro-
gram in helping other addicts attain that which I have attained.

I find there is no real "hang-up" in using methadone. I leave a urine specimen
when I come into the clinic weekly and pick up six bottles of medication to
take hnme with me, which I take at my leisure. Methadone is a long-acting drug.
I take the drug at any time during the day, and sometimes forget to take it
and then overlap hours. The drug lasts anywhere from 24 to 30 hours. I have
never experienced any withdrawal symptoms.

As I say, there is no drug craving, and no outw^ard appearance of euphoria.
^Methadone does not produce these symptoms as other opiate drugs do.

In the time I have been on the methadone program, I find that there are many
people who are willing to take a chance on the addict population once they
(the addicts) are stable on it, that is, the maintenance drug. In New York City
alone we have many large organizations, such as the telephone company and
large construction firms, who are willing to employ some of our people in the
program.

It is difficult for me to tell you all of the things that have happened to me
in the past. I have a new life today and it is something that T was never able to
have before.

[Exhibit No. 13(b)]

Beth Israel Medical Center,
Methadone Maintenance Treatment Program,

New York, N.Y., May 7, 1971.
Mr. Chris Nolde.

Associate Covnsel, House Select Committee on Crime,
Washington, B.C.

Dear Mr. Nolde : Following are my comments concerning the statements of
Mr. Horan :

1. We agree that private physicians should be regulated in their use of metha-
done for maintenance ; but we should be careful not to impede the development of

254

well-structured methadone maintenance programs because of the improper use
of methadone by private physicians.

2. Methadone in injectable form (Dolophine) has been available in the legal
and illicit markets for a long time. It is inaccurate and misleading to ascribe
methadone overdoes in any community to the existence of methadone programs
alone since Dolophine has been available for many years and is still available
in the illicit market. Most structured programs do not use Dolophine in pill
form.

3. Although methadone maintenance is not the treatment of choice for all ad-
dicts, it should be available for those for whom it is the treatment of choice.

(a) We have changed our admission criteria as follows :

(1) Minimum age requirement has been reduced from 20 to 18 years.

(2) Number of years of verified addiction has been reduced from 4 to 2
years.

We made these changes in order to make this treatment available to the
younger patient who is already thoroughly addicted to heroin ; in this v\-ay we
can treat the younger patients who need the program without addicting persons
to methadone who are not already clearly addicted to heroin.

(b) We find that most, if not all of our patients, have been treatment failures
in other programs; but this is not an absolute prerequisite for admission.

4. We agree that every effort must be made to screen out any applicant v.'ho
is not already addicted to heroin.

5. Therapeutic communities and residential treatment mentors are modalities
of choice for young and nonaddicted users of heroin. Communities containing
a significant number of addicted persons should provide programs designed to
meet their specific problem, including heroin addiction.

6. Part 5 of the statement reads in part : "We find many provable cases of
injection directly into the vein of methadone mixed with juice or Tang." I have
checked with our clinical staff to make sure that my impression is correct and
it is their opinion that the following is correct : Methadone mixed with juice or
Tang is nouinjectable for several reasons which I think are too technical to go
into here, but the fact is that the drug in this form is not injectable and any
patient who succeeded in injecting it would become fatally ill.

I would emphasize that there is a large group of chronic heroin users for whom
all existing treatment programs except methadone maintenance have been a
failure.

The goal should be to set up structured, controlled programs and not to deny
the seriously heroin addicted this proven program which is literally lifesaving.
both for the patient and the community.
Sincerely yours,

HaPwVey Gollance, M.D.

Asfnciatc Director,
(In charge of narcotic trcatmcitt proyranis).

[Exhiliit Xo. 13(c)]

FoRTY-NiNTii .Judicial Distuict,
Counties of Dimmit, Wekb, Zapata,

Laredo, Tex., November 11, 1070.

Vincent P. Dole. M.D.,

Rockefeller I 'nirer.sity,

New York, N.Y.

Dear Sir: This is to notify you that a complete check of our district court
records reveal tiie following in connection with cases involving burglary and
theft, theft, aggravated assault, forgery, under the infiuence, and other' pettv
theft cases.

Our records reflect that since the inception of the methadone maintenance pro-
gram in Laredo. Webb County. Tex., the reduction in this type of crime has
dropped approximately 05 percent.
Very truly yours,

Carlos V. P.EXAvinES, Jr.,
A.'iS'Stant District Attorney.

Chairman PEPPEr.. The next witness is Mr. Robert F. Iloran.

Mi\ Horan is the Commonwealth attorney for Fairfax County, Va,

Mr. Iloran is a native of New Brunswick, N.J. He attended Mount
St. Mary's College, Emmitsburg, Md., where he received liis B.S.
degree in 1954. Following graduation, he was commissioned a second
lieutenant in the U.S. IMarine Corps and served as a Marine officer
until 1958. Upon leaving active service, he entered Georgetown Univer-
sity Law School and earned his LL.B. degree. He served as an assistant
Commonwealth's attorne_v during 1964 and 1965. In September 1965
he resigned as assistant Commonwealth's attorney to become a partner
in a Fairfax law firm. His law partnership terminated in March 1967,
when the circuit court appointed him Commonwealth's attorney to fill
an unexpired term, and in November 1967 he was elected to that office
for a term of 4 years.

Mr. Horan is a member of the Virginia State Bar, National District
Attorney's Association, Northern Virginia Trial Lawyers Association,
Delta Theta Phi Legal Fraternity, the Marine Reserve Officers As-
sociation, and the Young Democratic Club of Fairfax County. He is
a member and former secretary of the Fairfax County Bar Associa-
tion. Mr. Horan is first vice president of the Virginia Commonwealth's
Attorney's Association, and in March of 1970 he becam.e the first
elected chairman of the Northern Virginia Criminal Justice Advisory
Council.

Mr. Horan, we welcome your testimony.

STATEMENT OF EOBEET F. HOEAH, JE„, COMMOITWEAITI! ATTOE-
NEY FOE THE COTJI^ITY OF FAIRFAX, C0MM0IW7EALTH OF VIE-
GINIA

Mr. Horan. Thank you, Mr. Chairman.

I am the chief criminal prosecutor for a jurisdiction containing
upward of one-half million people. Prior to the year 1967, drug abuse
as a problem in what is essentially a suburban jurisdiction was prac-
tically nonexistent.

Commencing in the fall of 1966 and early 1967, we had our first
onset of drug abuse, as did most of suburban America. One of the
significant things that has happened to us and is pertinent for this
comniittee is that in the last 18 months in that jurisdiction we have
had five provable methadone overdose deaths. We have had tv/o others
that are probably methadone deaths. In the same period of time we
only had one heroin overdose death.

r am here today because of my increasing concern about the direc-
tion in which we are being pushed in the area of methadone main-
tenance. It seems that everyone articulates the position that metha-
done is not the panacea for heroin addiction, and yet in some quarters
it seems that that is exactly how we are treating it.

In my opinion, the news media has added massively to the con-
fusion concerning this drug. I sometimes get the feeling, and that
feeling was amplified by the WTOP editorial last week, that some
feel that methadone equals rehabilitation, and if a jurisdiction does
not have a methadone maintenance program they are simply not in
the rehabilitation business. WTOP's view, in my opinion, is patently

256

nonsense and serves only to add confusion to an already confused
situation.

The confusion is not alleviated when a physician can stand before
this committee, as one did in October of 1970, and state that the use
of methadone in treatment is "paralleled in importance only by the
discovery of penicillin during this century." I don't know what the
founder of the polio vaccine feels about that statement, but it strikes
me as grossly misleading.

First of all, I would like to make clear that I support a properly
run and properly controlled methadone treatment pi'ogram. Basically
I support the original concepts of the program of Dr. Vincent Dole,
in New York City. I firmly believe that with a certain class of addict,
there is nowhere to go but up. On the other hand, I believe that many
of the original Dole concepts have been prostituted on the altar of the
simple solution. Tliei'e is too much of an attitude in some quarters to
consign anyone and everyone who has used heroin to methadone main-
tenance, regardless of his state of addiction. Even Vincent Dole admits
that this method of treatment may consign its participants to a lifetime
of methadone addiction, since this compound is a physically addictive
one. I oppose such an easy consignment for two basic reasons :

One, because of the nature of hard narcotic use and the hard nar-
cotic users that we find in suburban Virginia — and I suspect that the
same would be true in most of suburban America — and two, the in-
creasing availability of this compound as a prime abuse drug.

In connection with the first reason, it is important to remember some
of Dr. Dole's original guidelines.

(1) The addict should be at least 20 years of age ;

(2) He should have at least 4 years mainline hard-narcotic addic-
tion; and

(3) Other methods of treatment must have been tried and failed
before he would be committed to maintenance.

I would suggest, members of the committee, that very, very few
addicts in sulmrban America would meet just those three guidelines.
In my jurisdiction. 77 percent of all our drug abuse cases, regardless
of drug, involves those aged 20 and below. The phenomena of drug
abuse hit us in 1966, while heroin abuse did not hit us until 1969, in
the spring. The net effect of this is that today virtually all of our
heroin users have less than 2 years' mainline addiction. Most, if not all
of them are below age 20 ; and when they first come to our attention,
no other method of treatment has been tried in an attempt to cure them.
Thus we can see that most of our addicts, and I use the term loosely, do
not meet Vincent Dole's original guidelines.

My concern is that in the search for the panacea for hard-narcotic
abusers we might consign to a lifetime of methadone maintenance
some very young kids without ever attempting another route of cure.
In my opinion, very few kids in my jurisdiction should be so consigned.
An analogy to "throwing out the baby with the bath water" might fit
our situation.

I would not for 1 minute contest the right of the District of Columbia
or New York City to commit themselves fully to massive methadone
maintenance programs. But please, for Heaven's sake, let's not commit
the rest of the country.

257

I guess I have read most of what Drs. DiiPont and Dole say about
their programs, and their writings certainly substantiate their commit-
ment— but their special jurisdictional needs appear to require it — my
jurisdiction does not, and I suspect that the rest of suburban America
is in my situation and not in theirs.

We presently have in Fairfax County a drug treatment program
based upon the therapeutic community concept.

We have been in the business for quite some time now. We are satis-
fied with our methods of treatment, and if there comes a time when we
have a large scale number of hard-narcotic abusers, then we are prob-
ably going to take a much harder look at methadone. But that is not
our situation today.

The second problem in northern Virginia involves the use of metha-
done as a prime abuse drug. Supposedly, the situation will be alleviated
by FDA regulations which may control the dispensing. I hope those
guidelines do that, because prior to any guidelines our situation was
atrocious. In the spring of 1970 the Fairfax Police Department and I,
after our second methadone overdose death, began to complain about
the availability of this drug in the marketplace. Unfortunately, three
more deaths were necessary before anything was done to tighten up
dispensing guidelines in the District, and two of those deaths involved
kids 16 years of age.

We have tried, through the treatment program, the police depart-
ment and my office, to evaluate our situation with regard to the avail-
ability of methadone. I would like to share with you some of the find-
ings that we made, based on a cold, hard look at it in the past year.

First. Large supplies of this drug have been coming out of the Dis-
trict of Columbia, primarily from private practitioners' offices. Much
of this methadone has been diverted into abuse circles and in some
cases it has become the drug of choice. Some of it is being sold right
in the syringe at $1.,50 a cubic centimeter. This makes it an excellent
profit drug and as much as in the case of at least one physician, he
distributes 50 cubic centimeters at a time at $15 a throw.

Upon resale of that at a $1.50 a cubic centimeter the profit is
apparent.

Mr. Peeito. Mr. Horan, has this doctor been prosecuted?

Mr. HoRAN. To my Imowledge he has not. We have no jurisdictional
control over him.

In the District of Columbia he can do exactly what he is doing.

Mr. Perito. Have you recommended to the District authorities that
he be prosecuted?

Mr. Horan. I have had a great deal of contact with the narcotics
squad over the year, and the district attorney's office, and they feel
their hands are somewhat tied. That is the impression I get.

Mr. Sandman. Why are they tied ?

Mr. HoRAN. Because, evidently, under the existing regulations he
can maintain an addict on methadone because he is making: a purely
medical iudgment, and. therefore, it is not criminal under District law.

Mr. Waldie. Mr. Horan, may I interrupt you ?

We are in the middle of a quorum call. I would like to have you
complete your statement before the end of the second bell. Perhaps

258

you best complete your statement and then we will come back for
inquiries.

Mr. HoRAX. The second thing we find is a number of cases of non-
heroin addicts being dispensed methadone in the District of Colum-
bia from private practitioners. These are kids that weren't addicts
to begin with, and they are getting methadone without being a true
addict.

You may have read about the reporter from the Northern Virginia
Sun who had never had a narcotic in his life, came over here, plunked
down $15 and he got methadone in a hand}' carryout dose.

Third. Methadone addiction appears to be growing at a faster rate
than heroin addiction. Our drug treatment program over the past
year found it necessary to engage in medical detoxification of 39 pa-
tients. Thirteen of these were detoxified for a heroin habit and 26
were detoxified for a methadone habit. A large majority of those de-
toxified were below age 20.

Fourth. Some of the users were obtaining methadone by going to
one physician on one da^?- and a different physician a couple of days
later. This resulted in their being able to obtain a weekly supply from
each physician in the same week.

Fifth. Dr. Vincent Dole originally felt that one of the main reasons
for dispersing methadone diluted in fruit juice was that nobody would
shoot it. We find many, many provable cases of injection directly into
the vein of methadone mixed with juice or Tang.

As a matter of fact, the interior of the lungs of one of the recent
death cases was coated with a material that was consistent with
methadone abuse. There is only one way to get that on the interior
lining of the lungs, and that is through a vein.

Many cases of nonfatal overdose began to show^ up simply because
methadone was entirely too much drug for the drug abusers in our
area, particularly when it was being injected rather than taken orally.
An addict may have been getting 2- or 3-percent heroin in his vein
and all of a sudden he is getting a relatively pure drug in methadone
and his central mervous system can't stand it. His respiratory system
fails, he stops breathing.

Sixth. A great number of our citizens were not even aware that
their youngsters were involved in a so-called methadone treatment
program in the District. Their kids were in treatment programs. They
didn't know the treatment involved the daily dispensing of phj-sically
addicting narcotics.

In conclusion I want to say that methadone maintenance probably
does have a proper place and is the only mode of treatment in sonic
cases. However, I strongly endorse the caveat of this committee, at
page 82 of its report of January 2, 1971, entitled "Heroin and Heroin
Paraphernalia," where in this committee said :

Every precaution against diversion mnst be olxserved. While we believe tliat
drug should be reclassified, we do not believe that individual private practitioners
should be allowed to prescribe methadone for prolonged maintenance of indi-
vidual heroin addicts.

The footnote to that caveat gets to the heart of tlie issue, in my opin-
ion, where tliis committee states: "Methadone maintenance must be
accompanied b}' proper psychiatric, social, and vocational services.''

259

- I would only add to that the suggestion that maintenance should not
be the original mode of treatment except in an isolated class of cases ;
and secondly, that in the case of many young suburban abusers proper
psychiatric, social, and rocational services will obviate/ tjiie necessity
of maintenance to begin with. \ ■, .,.

Mr. Waldie. Thank you, Mr. Ploran.

There will be, I am sure, a number of questions to be asked of you.
Hopefully we v^^ill reconvene at 1 o'clock.

The committee will remain in recess until that time.

(Thereupon the committee recessed to reconvene at 1 p.m.)

Afternoon Session

Mr. Mann (presiding). The committee will come to order.

Prior to the recess, Mr. Horan was testifying and we will resume
his testimony.

Mr. Horan, you had completed your statement in chief ?

Mr. Horan. Yes ; I have, sir.

Mr. Mann. All right ; Mr. Perito, will you inquire ?

Mr. Perito. Thank you, Mr. !Mann.

Mr. Horan, I assume from your testimony that you are not opposed
to properh^ run methadone programs ; is that correct ?

Mr. HoKAN. Tliat is correct.

j\Ir. Perito. It is the thrust of your testimony then, if I underst.md
it, that you consider that your problem is different from the problem
in the District of Columbia or in New York City; would that be
correct ?

Mr. HoRAN. I certainly think that is so, predominantly because I
think we have a different breed of addict than New York City has,
sir.

]Mr. Perito. Would NTA be the type of program that you point to as
an example that you could support ?

Mr. HoRAN. That may be a little far.

From the point of view of the one issue of the ability to di\'ert
methadone into drug abuse circles, I have no evidence that we have
ever seen any methadone in our area that has come out of NTA.

From that point of view I am satisfied with the NTA controls at this
point in time.

On the second issue, my difficulty with NTA is that they appefir to
be, on the surface, entirely too methadone prone. That seems to be
the big thing with them as opposed to what I think is a growing tend-
ency in research programs to indicate that different modes of treat-
ment are necessary.

Mr. Perito. And you believe that the propensity toward methadone
distribution in a clinical setting causes you, as a prosecutor, problems?

Mr. Horan. Yes ; I think so.

Mr. Perito. And those problems come from diversion ?

Mr. Horan. They come from diversion. They also come from '^he
psychological attitude, if you will, that methadone is the cure, and vou
find an awful lot of addicts, who discover it really isn't the cure, it is
just another drug for those addicts. It just continues to be a difficult
criminal problem.

260

Mr. Pertto. Based upon your experience, have you found diver-
sion on a manufacturing level in Fairfax County ?

Mr. HoRAN. No ; we have not.

Mr. Perito. I assume that based upon your experience your diver-
sion is found on the low levels of dispensing, say from private
physicians?

Mr. HoRAN. Almost entirely private practitioners.

Mr. Perito. Have you found any evidence of diversion on the drug-
store level?

Mr. HoRAx. There is a recent report by the Virginia Board of Phar-
macy. An investigator who did a report for the Virginia Board of
Pharmacy found virtually no diversion anywhere in the State.

Mr. Perito. So it is fair to say that ordinarily, and based on your
experience, the diversion which causes you problems, as a prosecutor,
comes from private physicians ?

Mr. HoRAN. Yes ; it does.

Mr. Perito. Based upon your experience, how do you think that
diversion problem can best be handled ?

Mr. HoRAN. I feel at this point in time a private practitioner simply
should not be in the business. He should not be in the business of
methadone maintenance. My feeling is that I have never seen a prac-
tioner in the metropolitan area of Washington who I feel has the
pi'opcr supportive services to go along with his program so that he
is an effective rehabilitation mode. I think that with the average physi-
cian we have run into in the metropolitan area of Washington, all he
is is another drug seller. I would hate to think that organized crime
ever wants to move in under the guise of a medical license. Organized
crime might move into the dispensing of methadone, because it is a
high-profit drug as it is being dispensed privately.

Mr. Perito. You presently have operating in Fairfax County thera-
peutic communities ?

Mr. HoRAN. Yes ; we do.

Mr. Perito. I assume by that you mean a drug-free community ?

Mr. HoRAX. Yes.

Mr. Perito. And they only use methadone as a detoxification drug?

Mr. HoRAN. Actually the treatment center, itself, does not use metha-
done at all in treatment. We use methadone in the jail facilities as a
withdrawal drug to detoxify an addict.

Mr. Perito. How long has the therapeutic facility been in operation
in Fairfax County ?

Mr. HoRAiSr. Since September of 1969.

Mr. Perito. Do you have any statistics from that facility as to the
efficacy of their approach insofar as the reduction of crime or incidence
of antisocial behavior is concerned ?

Mr. HoRAN. I don't have any specific statistics that could prove it
one way or the other. I do know that of those in the treatment pro-
gram wc have had very few that we later see in the court scene as a
criminal statistic.

Ml-. Perito. Do you know, as a genei-al matter, whether therapeutic
communities have been successful in reducing the crime rate of addicts
under treatment ?
Mr. Horan. I think probably they have been.

261

Mr. Perito. Is your thinking based upon studies that you have
seen?

Mr. HoRAN. Mostly the reading that I have done in the area, from
other parts of the country.

Mr. Perito. If you have any of those studies, I would appreciate
you making them available to the chairman of the committee.
Mr. IIORAX. I certainly will.

(As of the time of printing of this record, the committee had not
received the studies or statistical evaluations from Mr. Horan of the
efRcacy of drug-free clinics insofar as the reduction of crime or anti-
social behavior is concerned. )
Mr. Pepper. Mr. Blommer.

Mr. Blommer. Mr. Horan, would you say that in Fairfax County
(here are very many drug takers that you would call addicts, as op-
posed to drug experimenters or drug users ?

Mr. Horan. The head of ou]- Fairfax-Falls Church Mental Health
Center, a psychiatrist, refers to our population of drug abusers as
1)eing garbage collectors. By that he means they will take anything,
regardless of what it is, or what form it is in.

I would suspect an overwhelming percentage of our kids are in
that boat. They will use anything. They aren't committed strongly
to any one drug, by and large.

We tried to figure out the other day, sitting down, tried to put
together a list of those we thought were anyv>^here near 4 years in
the vein, and we couldn't come up with 10, and most of them were
addicts that we had dealt with, 7, 8 years ago, coming out of the city
of Alexandria, mostly. They are the only ones we could come up with.
Most of our kids are diversified drug users. They have tried heroin
a few times here and there, along with a number of other things, and
they aren't in the vein that heavily.

As a matter of fact, I can recall no case of a jail prisoner who
took much longer than 20 hours to be completely detoxified. Most
show absolutely no withdrawal symptoms after the 20-hour mark.

As a matter of fact, we have had kids come in, who supposedly
had big drug habits, who never show any withdrawal symptoms the
whole time they were in the jail.

Mr. Blommer. Mr. Horan, do you have what you would call a black
market in drugs in Fairfax County and if so, what drugs are available.
Mr. Horan. I think they are all available, unfortunately. I think
our drugs essentially come from about three major sources.

First, I would be in the hard narcotics field, heroin and maybe some
morpliine on rare occasions. That almost invariably is coming out of
the wholesalers in the District of Columbia. I know of only one whole-
saler that we have ever dealt with in Fairfax County in the heroin
area. That is one source.

The second source is the methadone source which appears to be
private practitioners in the District.

The third source is the ximerican free enterprise system at its best,
and that has to do with marihauna, LSD, and hashish, and there it is
a very amateur, nonprofessional, somewhat noncommercial market
where kids are using a tremendous amount of ingenuity to come up
with drugs.

262

A a'reat case in point was a conple of years airo I had a phone call
from th<? ]>r;)secutor in Lincoln County, >7ebr., Foit PJafte, Kebr. Pie
wanted to know if we had a kid in our coinmunit}', for want of a better
name, Joe Blow, and I said yes, we did. As a matter of fact, we were
prc^eciitinir him for a drn^ oifense at that time. They had just picked
him up in ISTebraska with liis trusty sickle in hand, he was cuttinj^
down a field of marilmuna in Lincoln County, Xebr., and had 17-
pouuds in the trunk of his car when the Lincoln County, Nebr., police
arr-psted him.

H? is th.e free enterpri'-e type who would come back with a tremen-
dou'^ amount of marihauna for sale.

Ml-. Blommer. You liave said tliat you find that methadone in your
black market comes from physicians in the District of Columbia that
are jirescribinjT; it. Are there any physicians in Fairfax County that
are prescribing methadone that you feel is entering in that black
ma rket ?

Ml". HoRAisr. No; we can't show any physician in northern Virginia
add'ug to the black market. We have a couple of cases that involve
aboi!^ eiirht persons who are receivino; metliadone maintenance from
Virginia physicians, but we find no indication of diversion.

Mr. Blommer. If you found a doctor in your county that you felt
was more of a peddler than a healer, is there any statute in the State
of V' rcinia that you could use to prosecute that doctor ?

Ml-. IToRAN. Yes; I think we could prosecute him under our Drug
Coutrol Act.

Mr. Bf o^FMER. You have heard Dr. JafTe refer to his law. Then the
Stat.'^ of Virginia has a comparable law?

M:-. HoRAN. It is comparable law. In my opinion as a prosecutor it
would be very, very difficult to get a conviction because I think you
run into the basic ]>i-oblem that tlie physician sitting there before a
jury, he can lay it all off on the medical considerations, I made a medi-
cal judgment and this w^as my mode of treatment.

I think you would have trouble convicting him imder the statute.

I think, in Virginia, a far better vehicle would be to go through
the State board of medical examiners to revoke his license, or in the
case of pharmacists, the State board of pharmacy to revoke his license.
I think that would be a far better method of getting at the corrupt
practitioners than would be a criminal prosecution under the Drug
Control Act.

Mr. Blommer. Would you favor Federal legislation in this area?

Mr. HoRAN. I am totally in favor of Federal legislation that sets
up strict controls on methadone availability. One of the reasons I feel
so strongly about it is that I know that for a year we banged our
heads against a brick wall to try to cut down the availability of this
drug that was coming out of the District of Columbia.

We have been totally unsuccessful. We have got three deaths to
prove it. It seems to me only Federal legislation is going to control
that situation, at least as far as Virginia is concerned.

Mr. Blommer. Thank you, JVIr. Horan,

That is all the questions I have, Mr. Chairman.

Chairman I^epper. Mr. Mann ?

Mr. ]Mann. No questions.

263

Chairman Pepper. Mr. Steiger ?

Mr. Steiger. Thank you, jMr. Chairman.

Mr. Horan, to your knowledge, has any physician ever been charged
in the State of Virginia under the statute to which you just referred?

Mr. HoRAx. Yes ; I think there have been charges under that statute.

Mr. Steiger. To what degree of success ?

IMr. HoRAX. The net effect was that the physician just turned in his
license and the prosecution ended there. They didn't pursue it.

IMr. Steiger. He didn't continue the practice of medicine?

Mr. HoRAx. He lost his right to practice medicine.

Mr. Steiger. You mentioned in several instances of private physi-
cians in the District of Columbia who are the source of diverted
methadone. How many are we talking about ?

Mr. HoRAX. At least four.

Mr. Steiger. At least four.

And you know who they are ?

Mr. HoRAX. Yes ; I think we have a good idea.

Mr. Steiger. What kind of volume are we talking about. I ^uess the
thing that would really interest us would be not only that which finds
its way into Fairfax, but that which is being diverted in the District,
also.

Mr. HoRAx. One example that I can give you is in the case of one
specific physician. We have had him under surveillance a number
of times over in the District because we feel that at least two of the
drug deaths we have are related to his supply.

In the course of surveillance of this physician there was never a
time when the physician had less than 10 patients an hour in his office
at $15 a throw. If you give him a six-hour day and a 5-day week, he
has about $325,000 gross minimum in just his dispensing habits.

Mr. Steiger. Excuse me. All of these patients, based on your observ-
ance, were receiving methadone ?

Mr. HoKAX. Yes ; everybody that was in there. That is what he is
there for.

Mr. Steiger. He didn't do much else ?

Mr. HoRAX. He is supposedly a general practitioner, but I think
his main business is methadone. In his case, he is dispensing in a form
that is probably costing him $0.25. In my opinion, the whole treatment,
at least as we know it, has to do with dispensing methadone and
nothing more.

Mr. Steiger. Right.

Mr. HoRAx. There are no rehabilitative or vocational services.

Mr. Steiger. Do you know the form, the physical form ?

Mr. HoRAx. Methadone mixed in Tang.

Mr. Steiger. It was the same form in which it is given at the clinic
as you described ?

Mr. HoRAX. That is right.

Mr. Sreiger. It has been your experience, which you stated in your
statement, that contrary to some of the medical opinion we had that at
least one victim apparently did shoot the mixture in the Tang ?
Mr. HoRAX. Every one of our dead ones was in the vein with metha-
done; in one case it was the methadone mixed in Tang. Every one
of them was shooting but only one of them, to my knowledge, had
Tang.

264

Mr. Steiger. Did you discuss with the District of Columbia author-
ities this particular physician ?

Mr. HoRAN. Yes ; I did.

Mr. Steiger. Did they corroborate your observance?

Mr. HoRAx. As a matter of fact, the District of Columbia Police
indicated to me that on four occasions they had detectives who went
to this doctor's office and got methadone.

Mr. Steiger. Do you know what action they took against him ?

Mr. IIoran. There was a grand jury proceeding, and the grand jury
did not indict. I am only basing this on hearsay, as to what the grand
jury proceeding was. There has never been a prosecution for illegal
dispensing against that physician.

Mr. Steiger. Is there an AMA organization in the District?

Mr. HoRAN. I believe there is.

Mr. Steiger. Do you know if anybody has called this matter to their
attention ?

Mr. IIoiLVx. I think it has been. I think it has been brought to the
attention of the D.C. Medical Society.

Mr. Steiger. As far as you know — this fellow — there was no action
taken to limit this activity ?

Mr. HoRAN. No ; there was not.

Mr. Steiger. Now, these other three that you are aware of, are they
conducting as extensive an operation as this gentleman?

Mr. HoRAN. One of them may be bigger.

Mr. Steiger. Is it possible that there are other physicians that you
aren't aware of?

Mr. HoRAN. Oh, yes; I am sure of that. "What happens to you. I
think, is that certain physicians develop a name in drug circles, that
name is mentioned, and it is kind of a public relations program to be-
come known and then you become the source.

I think that is what happens. Maybe the kids in ^Montgomery
County are going to someone else; I don't know.

]Mr. Steiger. Have you ever checked with the FDA to find out if
any of these four have a so-called IND number issued by the FDA ?

Mr. HoRAN. I have checked with them on two of them and they do.

Mr. Steiger. They do ?

Mr. HoRAN. Two of them do.

Mr. Steiger. What was the response of the FDA when you advised
them of your observance ?

Mr. HoRAN. We never had an awful lot of success with FDA. I
guess we had about as much success as the Bureau of Narcotics and
Dangerous Drugs. There seem to be some loggerheads between the two
of them as to what the policy should be. I final Iv brought it to the
attention of Virginia's two U.S. Senators and "at least, based on
the speech that Senator Byrd gave on the floor of the Senate, he didn't
have an awful lot of success with FDA, either.

Mr. Steiger. I think loggerheads is a very general philosophy.

I take it, then, as recited both bv the chairman and INTr. ^Nlann.'and T
guess everybody else, that you do favor very specific Fodornl statutes
which obviously would be applicable in the District of Columbia «

Mr. HoRAN. Yes, sir ; I do.

265

Mr. Steiger. Limiting the dispensing of methadone ?

Mr. HoRAN. At this time I don't think private practitioners should
be in the business.

Mr. Steiger. Based on your testimony, at an estimated cost of 25
cents, this man is making a profit of $14.75 a patient, less the overhead
for rent and lights and heat, and at the rate of 10 patients an hour,
he is there for somewhere in the neighborhood of $150 an hour ?

Mr. HoRAN. At least.

Mr. Steiger. Mr. Chairman, I won't pursue this any further, but I
would like to compliment the staff and Mr. Horan for spelling this out
so specifically. I think one of our basic problems has always been the
tendency to accept the medical profession as being incapable of the
kind of action you described, and I, for one, have never subscribed to
that, the sanctity of any profession. They are just people, and I would
hope that we would be able to do something, Mr. Chairman.

Chairman Pepper. I am sure the committee will give very serious
consideration to that problem.

Mr. Horan. I would suggest, Mr. Chairman, if I might, I think one
of the difficulties that you run into is that by and large medicine as a
group has never paid much attention to this subject because it was just
beyond normal medical needs. I think what has happened is that you
do have a very small percentage in the clinical end, and of course they
are some of the great minds on the subject, Jaffe, Wyland. and Dole.
Those are the people who have the most experience with it. Medicine
generally has never dealt with it.

It is not taught in medical schools. When the private practitioner
gets into this business he is dealing with a very difficult situation be-
cause he is not really in a knowledgeable position.

Chairman Pepper. If I may corroborate what you said, my wife and
I have been identified for a long time with the Parkinson Foundation
and Institute, and we have come in contact with some of the outstand-
ing authorities who have developed and discovered methods for the
practical application of L-Dopa in the treatment of Parkinson's dis-
ease, and these authorities say very strongly that the average practi-
tioners should not be permitted to give L-Dopa because they don't
know that much about it.

I know a Senator here in the Congress right now who was being
given, by certain medical authorities, large quantities of L-Dopa. One
of the outstanding authorities in the country visited the Senator and
reduced his dosage very much and he improved, because it is a spe-
cialized subject and you have to know a lot about it before you can
wisely dispense it.

JNIr. HoRAN. Yes, sir.

Chairman Pepper. Have you finished ?

Mr. Steiger. Yes, sir.

Chairman Pepper. Mr. Rangel.

Mr. Rangel. Yes.

Mr. Horan, you support the efforts being made b}^ the District of
Columbia and New York City in the area of treating addicts with the
use of methadone ?

Mr. Horan. Yes ; in a certain class of cases.

]Mr, Rangel. And you also support its use in the jails of Fairfax
County ?

60-296— 71— pt. 1 18

266

Mr. HoRAN. We don't support it as a matter of maintenance, only as
a matter of withdrawal.
Mr. Kangel. For detoxification ?

Mr. HoRAN. Right ; bring them down, and we bring them down in-
side of 48 hours.

Mr. Rangel. What is the ethnic composition of the drug addicts in
Fairfax County?

Mr. HoRAN. That is a good question. INIy county is about 5 percent
black. Using the normal phrase "minority group," I don't think there
is a high percentage of any other minority group in my county. Yet
in the year 1970, of 322 prosecutions only 10 of the 322 were blacks.
In our black community, by and large, we never really had a drug
problem until the fall of last year when one major dealer — and this is
the only real wholesaler I have ever dealt with in the heroin field —
moved into our black community, began a selling operation, and un-
fortunately about the time we got into the act there were a number of
15- and 16-year-old blacks in the vein, pretty serious heroin habits.

Of course, Ave never would have cracked it, except for a District of
Columbia policeman. He is really the one who cracked it for us.

Mr. Raxgel. So your overwhelming population in Fairfax County
is white ?

Mr. HoRAN. That is right.

Mr. Rangel. If you had to give a general classification, what would
they be, middle income ?

Mr. HoRA>r. High-middle income. In median income we are about
the third or fourth county in the count r3% I think.

Mr. Rangel. Were you here earlier when I asked Dr. Jaffe whether
he thought that the medical profession had established a different
standard in taking care of the problems, medical problems of poor peo-
ple as opposed to the medical problems of middle income people ?
Mr. HoRAN. Yes; I heard that question, and I thought about that.
Mr. Rangel. Aren't you really supporting that type of thing in
your testimony today ?

Mr. HoRAN. No. I feel this wa^-, and I feel pretty strongly about it :
You look at the statistics, the statistics still indicate that one-half of
all heroin addicts in the country live in the city of New York. Of those
in the city of New York, let's face it, most of tliem come from Harlem
or Spanish Harlem. As long as there Avas a problem in the city of New
York in those communities, nobody really cared, who cared outside the
city authorities ?

The rest of the countrs^ didn't worry about it, it wasn't their prob-
lem. I think, by and large, because it was the low-income groups in the
city of New York, no one cared.

That is a tragedy. I think we should have been learning something
from New York's 30 years of experience and we didn't.

On the other hand, I think that medicine by and large now sees it
on a large scale, all over the country. ]\Iedicine is looking at it, and
I think medicine, like everybody else, is scrambling for an answer. I
would not impute to medicine the motive that they are willing to take
the easy way out and just consign these low-income groups to
addiction.

Mr. Rangel. Let's look at it in view of your testimony. What you
are basically saying is that you would like 'to see medical science pro-

267

vide otlier ways to take care of your addict population rather than
relying on methadone 'i

Mr. HoRAN. Yes ; I would.

Mr. Raj^-gel. And you also say if the situation gets so bad in your
community that there is no way out except methadone, then, and
only then, will you consider this ?

Mr. HoRAx. Absolutely.

Mr. Rangel. I am asking you, would you not give the sam.e con-
sideration to the District of Columbia and the population of New
York City, that is, until you can evaluate that our addict population
has reached that point then you would have this same reservation about
the distribution of methadone for any community ?

Mr. HoRAx. I sure would.

Mr. Rangel. I am only hoping that the medical profession will
share your ideas.

Mr. H0R.VX. Of course, Mr, Rangel, my difficulty is in evaluating
New York. I, necessarily, have to rely on what Dr. Dole is saying,
Dr. Gollance is saying, what New Yorli's experts are saying about their
population, and they tell me in their writings that what they are
essentially aiming at is the guy who has been in the vein for many,
many years, the guy who is just fully, totally, and completely hooked
on heroin.

They are saying to me the only way we can treat them is with meth-
adone. My answer is, I don't know.

But I do know this, that I don't think methadone is the answer
if you have got a guy only 2 years in the vein and if they are com-
mitting New York addicts with 2 years in the vein to methadone,
I think they are wrong.

I think they should be going some other route of treatment,

]\Ir. Raxgel. So if my breed of addict, or a part of my breed of
addict, is similar to what you described as similar to Fairfax County's
breed of addict, we would share the same ideas ?

Mr. lioRAx. Yes ; I don't think the addict, the IT-, 18-, 19-year old,
I don't think he should be committed to a methadone mamtenance
program at that age or with that short a term of addiction. When I
ttilk of breed of addict, really what I am talking about is in New
York where you have a lot of people who have been in the vein 10
years, I don't have any of those. But I think that those that are in
the same position as mine, the 18-year old who has been in the vein
for a year, I don't agree with New York putting him on methadone
any more than I agree with Fairfax County putting him on
methadone.

Mr. Raxgel. Mr. Chairman, I want to join in with my colleagues
and thank the staff for bringing Mr. Horan before us. I think it sub-
stantiates the fact that not everyone has just accepted methadone as
a solution to our present problem.

Thank you, Mr. Horan.

Chairman Pepper. We all will profit very much from your testi-
mony.

We have some more questions.

Mr. Winn.

Mr. Wixx. Thank you, Mr. Chairman.

268

Mr. Horan, let's back up a little bit. Over in Fairfax County, those
that are on drugs, the kids that are on drugs, a high percentage of
the users are on marihuana ; right ?

Mr. HoRAx. Well, a less high percentage all the time. In 1967 one
case out of every 10 would be a stronger drug than marihuana. By
last year it was one case out of every four. I think there has been a
real graduation of marihuana users.

Mr. Winn. The percentage of those who were on marihuana have
switched and gone to the harder drugs in the percentage of one out
of four now ; right ?

Mr. HoRAN. Yes.

Mr. Winn. All right. Physicians prescribe all kinds of drugs for
different things, which is within their realm. It is a little hard for
me to comprehend that all the bad guys are in the District of Columbia,
physicianwise, and all the good guys are in Fairfax County.

Mr. Horan. I wouldn't want to create that impression although,
you know

Mr. Winn. I think maybe we have.

Mr. Horan. In fairness to our medical society, I would say abso-
lutely that one of our real sources of help out there has been the medi-
cal profession. I think they police themselves.

Mr. Winn. That leads me into the next question : Do you think it
is because of the strength of the Fairfax County medical society that
they are keeping a stronger and tighter rein on the doctors and physi-
cians over there that might be prescribing, say free lancing, methadone
compared to the District of Columbia ?

Mr. HoRAN. Yes, sir. I think that is probably part of it. I think
another ])art of it is the fact that when the drug phenomena hit us in
1966, medicine got in the act early, and medicine began taking a look
at this subject that they knew nothing about.

Let's face it, the average physician, if he is below age 25, he never
had a course in medical school that involved the three main abuse
drugs in society today, LSD, marihauna, and heroin. They aren't
taught in medical school because they have no therapeutic value.

Mr. Winn. They are still not being taught now ?

Mr. Horan. Well, Georgetown

Mr. Winn. But not nationwide ?

Mr. Horan. No ; it is not.

So medicine, first of all, in a community such as mine, has got to
get into the act to understand it to begin with, because they are in a
foreiirii field, just like every layman out on the street.

Our medical society did that. Our medical society took a good hard
look at prescribing practices, which I think is really the key.

I think medicine has got to look at themselves and say what are we
doing.

Mr. Winn. Right. That clarifies that, because I don't think you
really made that clear, at least I didn't get it that way in the earlier
testimony.

Now, the Drug Control Act is basically controlled again by each
State. That would go right along with the same vein of thinking,
depending on which State is really going to clamp down and wliich
ones are going to close their eyes to some of the acts ; right ?

269

Mr. HoRAN. That is right.

Mr. Winn. Which would come into effect possibly again because
of the control and the District of Columbia control might be lighter
than in Virginia.

Mr. HoRAN. I think that is right.

Mr. Winn. Okay.

Well, I don't know about Baltimore — how about Baltimore?

Mr. HoiLVN. I never had all that much experience with Baltimore.

Mr. _ Winn. All right. You mentioned several times the history of
the jail cases, and I understood you to say that you have a system, I
believe you referred to some hours and you said 24 hours as an aver-
age for getting them detoxified ?

Mr. HoRAN. Most of the time, they are detoxified in 24 hours.

Mr. Winn. Twenty-four hours ?

Mr. HoRAN. That is without any

Mr. Winn. Yes ; right.

Mr. HoRAN. "\^^ierever it is felt that they need help to come down,
it is all over in 48 hours.

Mr. WixN. Then you use methadone ; right?

Mr. HoRAN. Jail physicians prescribe Dolophine in a certain amount
and that is what the prisoner gets and it never goes over 48 hours.

Mr. Winn. What is their reaction to the methadone within that
48-hour period ?

Mr. HoRAN. It all depends on what kind of addict they are.

Mr. Winn. Give us the worst example and give us — and the lightest
one obviously would have no reaction, probably. The heaviest

Mr. HoRAN. One of the things you constantly have to watch for is
the kid who comes in there and the first thing he is saying when that
jail door closes is, get me the methadone, because the word is out
among that breed that you can get this stuff if you qualify and you
may have a rruy coming in there that isn't really any addict at all, and
he wants methadone because he is going to get high.

Two davs in jail high beats 2 days in jail any other way. So he wants
it. ■ ^ _

Mr. Winn. How does he get hisfh on oral methadone that is taken
with Tang?

Mr. HoRAN. Anybody who says you don't get a high on methadone
is dreaming. I am talking about you and I. The problem is — and I see
the newspapers constantly use this term — a "noneuphoric substitute
for heroin" — it is not a noneuphoric substitute.

If you are talking about a guy who has been in the vein 5 years,
yes; but you know, you could do anything to that guy and it is going
to be noneuphoric compared to heroin. With most other people we
get a high.

Many women today in hospitals after a very difficult delivery, the
prime druff used the following day after the delivery, if the woman
is in pain and having problems, is what they call in the hospital Dolo-
phine, and that is methadone, same drug. They give her Dolophine.

You talk to anv woman who has ever hpd Dolophine and ask her if
it is euphoric. She says, "You bet your life. That is the reason they
gave it to me. it lifted my spirits and killed the pain. That is why
they gave it to me." It does have a definite euphoria on the scale.

270

It is not up to heroin or morphine, but it is probably on the level
with Demerol ; anybody who has ever had Demerol will agree it has
a good euphoria.

li a guy comes into jail and is really not an addict, he is going to
get a high.

Mr. Winn. Wait just a minute. I want to point out strongly, Mr.
Chairman, that this is in direct conflict with testimony we have heard
in the past from several of these other experts. I want to point it out
because it is completely different.

Chairman Pepper. Apropos of what my colleague said, the way I
believe it was stated by Dr. Jaife this morning was that with the first
little bit of taking of methadone you do get a high, but then if the doc-
tor giving it keeps on experimenting with the individual and gets to a
point where that person is stabilized and he doesn't get a high,

Wasn'tthat the gist?

Mr. Winn. I believe that was Dr. Jaffe's ptatem.ent, Mr. Chairman,
but I believe one of the other experts said that there was no euphoric
sensation from orally taken methadone.

Mr. HoRAN. I say that is flat out untrue.

I think the problem is that they are constantly asking a true addict
is there any euphoria, and he is telling the truth, for him there is
none, but he is comparing it to heroin. It is like the Irishman and the
Englishman seeing the guy la3'ing in the ditch. The Englishman said,
"Look, that guy is drunk." The Irishman said, "No, he isn't, he
moved."

It is about the same ball park, really.

There is medical research that will substantiate the fact tliat if
you get to a certain level of heroin use, say the guy who is maybe a
hundred dollars a day in the vein, he gets to a certain level where the
heroin itself is noneuphoric because he has gotten too high on the
scale, there is no euphoria left in the drug for him.

In fact, there are some in research who sav you could create the
same blockage M-ith high doses of heroin as you do with high doses
of methadone, because you reach the point where the drug itself
reaches the block.

Mr. Winn, Let me ask you one more question.

Of the drug deaths that you referred to, could the drug deaths be
from an overdose of oral methadone ?

Mr, HoRAN. That is a very good question. In two of the cases it
appears that the dead boy was taking it both orally and intravenously.
It could have been the combination, although our pathologist
suspects that because of the massive infusion when you go in through
the vein, that is what causes the quick respiratory system depression.

Mr. Winn. We have had some statements made here and the facts
presented to us, that some of the deaths not in Fairfax County, but
some of the deaths from methadone really proved out to be not deaths
from methadone at all, but a combination of lots of other things; is
that possible ?

jNIr. HoRAN. Sure it is.

Chairman Pepper. The committee has to go to the floor to vote.

We will take a brief recess. We will be back in a few minutes.

(A brief recess was taken.)

271

Chairman Pepper. The committee will come to order, please.

Mr. Keatinsr, ttouIcI you like to examine ?

]Mr. IvEATixG. ^Ir. Horan, I was not here for your entire testimony.
However, the portions that I heard in the question and answer por-
tion of vour statement I found to be excellent.

I think ]Mr. Ranp:el had indicated, and I agfree, that the goal we want
to achieve is rehabilitation and not total maintenance for the life-
time of the addict. So I don't have any specific question, but I wanted
to make those comments.

Chairman Pepper. Thank you.

]Mr. Horan, your testimony about the drug problem in Fairfax
County is of particular interest to those of us who are on this com-
mittee now who were members of the committee in the last Congress,
because either in the latter part of 1969 or the early part of 1970 we
held a hearing in Fairfax Countv, vou recall, in the courthouse?

]Mr. HoRAxrYes, sir : the fall of 1969.

Chairman Pepper. What interested us was that here was a very fine
county, composed of very fine citizens, high level of income, primarily
residential in character, that had a heroin problem.

I recall very well that we had some students from one of your high
schools who testified at our hearing and told about the prevalence of
drugs in the schools, the high schools.

So, you, as the Commonwealth's attorney of Fairfax, are telling us
that in 1969 the drug problem in Fairfax County became serious and
continues to be, I imagine, a very serious problem.

Mr. HoRAx. Yes, sir ; is it.

Chairman Pepper. Do you find that drugs, either in one way or an-
other, are related to the crime problem in your county ?

Mr. Horan. Mr. Chairman, we have seen in the last 2 years, anyway,
a veiy high percentage of drug-related crime. They aren't actually
coming into the court as a drug case, a drug prosecution, but in the
area of burglary or robbery. We had two murders last year where the
defense to the murder was that it was committed under the influence
of LSD. So we have seen a very high percentage of drug- related crime.

Chairman Pepper. So you are concerned about the drug problem in
relationship to crime primarily as the Commonwealth's attorney.

You have observed, as a prosecuting attorney, certain reactions to
the use of methadone which have also concerned you and which you
have been very ably telling us about here today. You are speaking, of
course, out of your experience as a prosecuting attorney, not as a medi-
cal doctor, I assume ?

Mr. HoRAN. That is right.

Chairman Pepper. I suppose we all agree that somehow or another
we must find a way of dealing adequately with the drug problem, par-
ticularly heroin problem, and we don't want to create another problem
in tryinsf to get rid of the first,

Mr. HoRAX. Exactly.

Chairman Pepper. You have raised a very serious question as to
whether or not a private physician, unskilled in respect to this sub-
stance of methadone and others of similar character, should have au-
tliority to distribute it. dispense it. There is always a possibility of
abuse. We are very much concerned about that very thinp-. We had "wit-

272

nesses yesterday who brought out the very question you talked about
here today, the danger of allowing private physicians to prescribe
methadone at will.

If it were to be distributed by a private doctor, would you consider
it desirable, if not imperative, that there be a registry so that every
doctor who did prescribe methadone would have to report it to a cen-
tral force or data bank so that any other doctor who wanted to protect
the public interest would have easy access to that information to know
what other doctors were prescribing, maybe in the same day for the
same patient, and also it would give an opportunity for somebody
looking at that data bank to see how much methadone, for example,
was being prescribed by any one doctor, whether he was making a pri-
mary business of that ; would you favor such a data bank ?

Mr. HoT^Ax. I would feel that, if the private practitioner is going
to be in the business, the data bank is absolutely imperative. I think
that is part of our problem here.

Second, I think ovce. a data bank was established, it should be moni-
tored by someone outside those who are in the business.

Chairman Pepper. Well, the last question is: Would you think it
desirable for the Federal Government to give very serious considera-
tion to trying to find something better and less objectionable than meth-
adone in dealing with this matter of breaking heroin addiction ?

Mr. HoRAN. Yes, I do, Mr. Chairman. INIy concern is with the ques-
tion of leaving a drug personality when you are finished with your
methadone program.

It would seem to me Federal money would be well spent in th_e
area of trying to come up with a different tool, a different ]>harma-
cological tool.

As a criminal prosecutor I sit there and when somebodv shows me
reduced crime rates I have got to be impressed ; that means something
to me. Maybe I am selfish. Maybe I don't like as much business as
I have.

1 would like to see a reduced crime rate. But I always have in mv
mind — what is the price? You know, we could reduf^e the rate of rnnp
by providing every rapist with a wom.an, for example, and you could
go to your handy service clinic and get a woman and then we cut rape
in half, or worse, and what is the price? I feel the snme wav about
methadone. What is going to be the price of having this many drug
personalities, and that's what we have when the drug is out in socie^v.

I think the Federal dollar would be well spent, coming up with a
deto-^ifi^ntion nnd ab'-tinence notential in another drnier.

T think the chairman mentioned before the possibility of coming up
with a drug that would make it revolting to have one narcotic.

With the American pharmaceutical mind we ought to be able to
come up with something like that.

Chairman Pept^er. We have discovered from onr A^arious hearings
that about half of the crime is related to drug use, and, therefore, if
we could cnt down drug use we would reduce crime.

That is the reason the House of Pepresentatives is concei^ned about
drugs. So we are dealing with something directly related to crime, are
we not ? T ask you as a prosecuting attorney.

Mr. HoRAN^. There is no question about that.

Chairman Pepper. Thank you very much.

273

Any other questions, gentlemen ?

Thank you, Mr. Horan. We appreciate your coming here today.

The committee's next witness is Dr. Daniel H. Casriel, a New York
psychiatrist who has long been interested in drug addict rehabilitation
programs.

Dr. Casriel received his medical training at the University of Cin-
cinnati, and served as a captain in the U.S. Army Medical Corps.

Dr. Casriel has served as court psychiatrist in the New York City
Court of Special Sessions; psychiatric consultant to the S^'nanon
Foundation ; clinical assistant professor of psychiatry at Temple Uni-
versity Medical School, and cofounder and medical-psychiatric direc-
tor of Daytop Village, a therapeutic community for addicts.

Dr. Casriel, in addition to the private practice of psychiatry, is the
director of AKEBA, an addict treatment program in New York.

He is the author of "So Fair A House," the story of Synanon, as
well as the author of several articles.

Out of your wide experience. Doctor, we are very much pleased to
have you here today. I am advised that you are accompanied by Dr.
Walter Rosen and Rev. Raymond Massy, who will supplement your
statement and respond to questions.

Mr. Perito, would you inquire ?

Mr. Perito. Thank you, Mr. Chairman.

Dr. Casriel, as you have been kind enough to provide us with some
written material and a statement by Dr. Revici ; is that correct ?

STATEMENT OF DE. DANIEL H. CASEIEL, DIEECTOE, ACCELEEATED
EEEDUCATION OF EMOTIONS. BEHAVIOE, AND ATTITUDES
( AEEBA) ; ACCOMPANIED BY EEV. EAYMOND MASSE Y. INSTITUTE
OF APPLIED BIOLOGY, INC. ; AND DE. WALTEE EOSEN

Dr. Casreel. Yes; I have given you some of the written material
and my remarks after Dr. Revici's initial lecture on his new drug called
Perse. I didn't give you the article that Dr. Revici has written, but I
assume you have that.

Mr. Perito. Yes ; we do.

Mr. Chairman, at this point I respectfully request that the materials
which have been furnished to us by Dr. Casriel be incorporated into
the record.

Chairman Pepper. Without objection, they will be received and will
appear following Dr. Casriel's testimony.

Mr. Perito. Dr. Casriel, you have worked with the addiction prob-
lem in a substantial portion of your professional life; is that correct?

Dr. Casriel. That is correct. Almost 20 years.

Mr. Perito. Is it fair to say that your therapeutic approach is an
amalgamation of your learning from Synanon and Daytop, plus
some innovative thinking of your own ?

Dr. Casriel. Also my training in Columbia Psychoanalytic Insti-
tute, my experience in Synanon, my establishment of Daytop, my ex-
perience in Daytop and my own private practice.

I have a new amalgam of treatment now which is different from all
of these and I find it clinically very effective.

274

;Mr. Perito. It is my understanding, Doctor, that in your treat-
ment ajiproach you have been using- a new experimental drug; is that
correct ?

Dr. Casrtel. Yes ; it is, Mr. Perito.

Mr. Perito. And that experimental drug can be properly referred
to as a rapid-acting detoxification drug?

Dr. Casriel. Yes ; it can.

Mr. Perito. That drug is nonaddictive ?

Dr. Casriel. It is nonaddictive.

Mr. Perito. Could you kindly explain to the chairman and members
of this committee what your experience has been with the use of this
drug ?

Dr. Casriel. Yes.

Chairman Pepper. You are talking about the drug Perse, P-e-r-s-e?

Dr. Casriel. Right.

I met Dr. Revici, the developer of this drug, a year ago last Febru-
ary, and I guess like most of you who might have seen it for the first
time, I didn't believe my clinical eyes, but in the past 14 months I am
convinced that this is a major breakthrough, on a chemical basis, of
the addictive phenomena of addiction.

I personally have given it to about a 100 addicts, about 30 of
whom have remained in my therapeutic community, called AREBA,
which stands for the Accelerated Reeducation of Emotions, Be-
havior, and Attitude.

I have never found any hai'mful side effects from Perse per se. It
has removed not only the addicting quality, but it gives the individual
a sense of well-being, the type of well-being he had before he was
addicted.

However, I would like to make sure that the committee realizes
there is a difference between an addict who is addicted, and an addict
who is not addicted.

After you remove the addiction you still have to treat the individual.

My work in the past 20 years has been with people. I have rehabil-
itated tlie addicted and it really doesn't make mucli difference what
they are addicted to, whether it is heroin, or morphine, or alcohol, or
homosexuality, or delinquency, or whatever.

The basic underlying personality structure has to be changed.

Perse has made my job much easier with those character disorders
called the addict.

Chairman Pepper. With what?

Dr. C ASPJEL. With those people, the psychiatrists call the addicted
personality.

Chairman Pepper. I see.

Mr. Pfrito. Doctor, is it fair to sav that you are drawinij a distinc-
tion between physical addiction and ps3^chic addiction ?

Dr. Casrtel. Yes ; there is a tremendous distinction. Perse removes
the physical addiction, the phA'siological addiction. It takes the type of
psychotherapy that I am doing, whicli is much different than classical
psychotherapy, to restructure the addict.

'■I think in terms of the physiological addiction, the physical ad-
diction, it is interesting that the several people I heard before me

Avho spoke about methadone and methadone blockade really have not
mentioned what do they mean by blockade, where does the location of
the blockading effect, what is the j^hysiological cause of addiction,
how does addiction work, what is addiction, how does it Vvork, v\'hy
does m.ethadone blockade, what does it blockade, et cetera, et cetera, et
cetera.

These answers have never been mentioned. I am aghast, really, that
this whole concept of methadone maintenance started with the re-
search, clinical research of six highly addicted heroin addicts by Dr.
Dole, who then transferred them to methadone and maintained them
on methadone.

Tliere is no theory, no pharmacological theory to substantiate meth-
adone addiction or methadone maintenance.

I met Dr. Eevici. He is a fine old gentleman. He speaks in such a
quiet voice and he is so esoteric it took me about a year to really un-
derstand his understanding of the nature of addiction, and if I may,
in the next few minutes, I would like to give this committee my inter-
pretation of his understanding of the nature of addiction.

He developed Perse with a pencil and paper. He theorized the
nature of addiction from his knowledge of intercellular physiology,
biochemistry, and pharmacology. With this theoretical approach he
then theorized the type of pharmacological type of drug that was
needed to solve it.

Chairman Pepper. That is the way Dr. Einstein developed the
Einstein tlieory, with a pencil and paper.

Dr. Casriel. On a piece of paper, a pencil and piece of paper, and
you might have said he never had enough money to do it any other
way.

He took this chemical and applied it successfully to thousands of
laboratory animals and then finally applied it to several thousand
patients that he has detoxicized from heroin without any harmful
effects.

I have detoxicized about 100 without any harmful effects whatso-
ever. I have personally taken some Perse, myself, to see the effect that
it would have in preventing — it also prevents alcohol addiction, alco-
hol intoxication — to see what it would do to me in preventing alcoholic
intoxication. Normally 2 ounces of alcohol taken by me will give me a
drunk and I fall asleep. One big cocktail will get me sleepy on an
empty stomach.

I took two of his capsules of Perse and proceeded to drink 8 ounces
of scotch without any side effects of dysarthria or intoxication. It is
true my belly felt a little bloated and my wife told me I smelled like
a kangaroo, but I was not drunk. I had no harmful effects.

I have no hesitation, if necessary, to inject this whole bottle of Perse
into me. I am that sure of its safety.

This is_a 100 cubic centimeter bottle. The addict only takes 5-10
cubic centimeters.

("hairman Pepper. Orally?

Dr. Casriel. Injectable, because we know how much is going in that
way. The first day about four times, the second about three times, the
third day twice and the_ fourth day one injection, and this is supple-
mented with the pills which are continued for the week.

276

So that at the end of the week this person is detoxicized from his
addiction.

Chairman Pepped. You mean if anybody had been taking heroin for
a protracted period of time and had that course of injections which
you just described, all in 1 week, that at the end of that week that
person would not have any further craving for heroin ?

Dr. Casriel. Wliile he is on Perse, no further physiological craving,
but if he stops taking Perse and takes heroin, he will get his old habit
back, his old euphoria.

The first injection of Perse immediately cuts down the amount of
heroin they need to sustain their addiction. I have seen people go from
iiO bags a day to one bag until they came to me the next clay and got
another shot of Perse.

Now, how does Perse work? Dr. Revici stated that heroin is an
alkaloid. iVn alkaloid is a building block of protein. Those chemicals
which are addictive are basically alkaloids building blocks of proteins.
Now, if you put a specific protein into your body like milk, you will
get a specific reaction to that milk, you will get a marked inflammed
area and you will develop certain antibodies to counteract the proteins
in the milk.

But an alkaloid is only a small portion of a protein and it doesn't
develop a specific antibody when it is injected. Instead, the body devel-
lops a generalized defensive substance which is a steroid, which com-
bines with the alkaloid, be it heroin, or methadone, or morphine. But
because it is not specific there is an overproduction of this steroid.

For instance, if one unit of heroin got into the body, the body miglit
manufacture in an analogous two units of steroids, one which combines
with the heroin and neutralizes the effect of the heroin.

The other one is free in the body. It is this free steroid which is not
attached to the heroin which causes the addictive phenomena, it causes
the craving phenomenon.

Now, when a person who has never used a narcotic injects a small
portion of narcotics into his body or takes it orally, the body's defense
system is activated. The injectable route is the quickest route. If you
digest it, it take a little longer to get into the bloodstream. The eftects
of the narcotics will be felt by the body, it goes to the brain centers.
It diminished the body's awareness of pain and it is a basic depressant.
One dies of an overdose because one's respiration stops and then the
individual stops breathing. That is how one dies of an overdose.

One of the lifesaving measures is to give artificial respiration imtil
the effect of the narcotic is passed out of the body.

Now, the body removes heroin in about 4 to 6 hours. It takes the body
about 36 hours to remove methadone. That is why one injection or
one pill of methadone can last at least 24 hours, Avhereas one injection
or one pill of heroin would only last 4 to 6 hours.

But when this heroin is detoxicized it is removed by the body, the
steroid whicli the body has developed previously to defend itself
against the hei-oin is free and it gradually develops an attraction to the
body tissue, sotting up a type of ])ulling or craving sensation. It sets up
in tile body what Dr. Eevici calls an anoxicbiosis, which when ti-ans-
lated into English means a negative oxygen metabolism. It is ver}'
similar to the type of pain and feelings you would get if a tourniquet

277

were tied around your hand. You get a negative oxygen metabolism
Avith an increase of lactic acid. The oxygen isn't present to break down
the carbohydrates in the body.

"Wliat we have then, after the injection of heroin after 4 hours, the
heroin goes through the body, we have this steroid which turns upon
the body which produced it, causing an anoxicbiosis. This is perceived
by the addict as a craving, as a yearning. As this anoxicbiosis builds
up greatei- and greater, depending on the amount of steroids, there is
localized acidosis that develops in the body and the body attempts to
compensate for this localized acidosis by a generalized alkaline reac-
tion. This is manifest clinically as the so-called cold turkey phenom-
enon. It is very uncomfortable for the addict to experience. It is seen
with high amounts of steroid — not high amounts of heroin — but a
high amount of steroid developed over a long period of addiction or
due to methadone maintenance. The blockading effect of methadone,
by the way, is just the overwhelming of the body's ability to produce
more steroids and the body then develops a tolerance for methadone,
just as some people who start to become heavy alcoholic drinkers can
show heavy tolerance for alcohol before they become drunk. I have
seen people drink 10 ounces of alcohol and look like they are sober.

But tlie steroid which has been produced in response to this foreign
alkaloid, remains in the body about 7 days. It takes about 7 days for
this steroid to break down. This is why it takes 7 days to detoxify some-
body from addiction. It takes 7 days to maintain a state of oxygena-
tion in the body while the steroid is being broken down.

Dr. Revici has developed other pharmacological tools to go along
with this basic tool called Perse. For instance, when a person has been
on methadone maintenance, for instance, he has so much steroid in him
that all the Perse that you give him still causes some side effects, you
just can't get enough of this oxygenizing substance into the tissue and
that is all that Perse is.

Mr. Perito. Doctor, excuse me.

Are you saying it is more difficult to detoxify a methadone addict
than a heroin addict ?

Dr. Casriel. Yes, because a person on methadone maintenance, has
tremendous quantities of defensive substance built up in them. Dr.
Revici has developed a substance which will temporarily combine and
neutralize the steroid in the blood and this is called trichlorbutinol.
It is an alcohol, but the interesting thing about this alcohol, it doesn't
develop more steroid.

For instance, if I have given a person who is really under tremen-
dous craving, and you know he has a large steroid component because
he has been on, say, methadone maintenance, I would give him, to-
gether with the Perse, some trichlorbutinol. Within 7 to 15 seconds he
feels better because that alcohol combines with the steroids in the
bloodstream. It takes about 7 to 15 minutes for the Perse to get into
the tissue to counteract the anoxiobiosis. If the person is already in
secondary stages of withdrawal, the cold turkey phenomenon, you can
give him a little hydrochloric acid to counteract the generalized alka-
line condition that he has.

If we know the degree of his steroid developed, we can